Doctor–patient relationship

The doctor–patient relationship is a central part of health care and the practice of medicine. The doctor–patient relationship forms one of the foundations of contemporary medical ethics.

Importance

A medical officer explains an x-ray to the patient.
The doctor is providing medical advice to this patient.
A physician performs a standard physical examination on his patient.

A patient must have confidence in the competence of their physician and must feel that they can confide in him or her. For most physicians, the establishment of good rapport with a patient is important. Some medical specialties, such as psychiatry and family medicine, emphasize the physician–patient relationship more than others, such as pathology or radiology, which have very little contact with patients.

The quality of the patient–physician relationship is important to both parties. The doctor and patient's values and perspectives about disease, life, and time available play a role in building up this relationship. A strong relationship between the doctor and patient will lead to frequent, quality information about the patient's disease and better health care for the patient and their family. Enhancing the accuracy of the diagnosis and increasing the patient's knowledge about the disease all come with a good relationship between the doctor and the patient. Where such a relationship is poor the physician's ability to make a full assessment is compromised and the patient is more likely to distrust the diagnosis and proposed treatment, causing decreased compliance to actually follow the medical advice which results in bad health outcomes. In these circumstances and also in cases where there is genuine divergence of medical opinions, a second opinion from another physician may be sought or the patient may choose to go to another physician that they trust more. Additionally, the benefits of any placebo effect are also based upon the patient's subjective assessment (conscious or unconscious) of the physician's credibility and skills.

Michael and Enid Balint together pioneered the study of the physician patient relationship in the UK. Michael Balint's "The Doctor, His Patient and the Illness" (1957) outlined several case histories in detail and became a seminal text.[1] Their work is continued by the Balint Society, The International Balint Federation[2] and other national Balint societies in other countries. It is one of the most influential works on the topic of doctor-patient relationships. In addition, a Canadian physician known as Sir William Osler was known as one of the "Big Four" professors at the time that the Johns Hopkins Hospital was first founded.[3] At the Johns Hopkins Hospital, Osler had invented the world's first medical residency system.[4] In terms of efficacy (i.e. the outcome of treatment), the doctor–patient relationship seems to have a "small, but statistically significant impact on healthcare outcomes".[5] However, due to a relatively small sample size and a minimally effective test, researchers concluded additional research on this topic is necessary.[5] Recognizing that patients receive the best care when they work in partnership with doctors, the UK General Medical Council issued guidance for patients "What to expect from your doctor" in April 2013.[6][7]

Aspects of relationship

The following aspects of the doctor–patient relationship are the subject of commentary and discussion.

The default medical practice for showing respect to patients and their families is for the doctor to be truthful in informing the patient of their health and to be direct in asking for the patient's consent before giving treatment. Historically in many cultures there has been a shift from paternalism, the view that the "doctor always knows best," to the idea that patients must have a choice in the provision of their care and be given the right to provide informed consent to medical procedures.[8] There can be issues with how to handle informed consent in a doctor–patient relationship;[9] for instance, with patients who do not want to know the truth about their condition. Furthermore, there are ethical concerns regarding the use of placebo. Does giving a sugar pill lead to an undermining of trust between doctor and patient? Is deceiving a patient for his or her own good compatible with a respectful and consent-based doctor–patient relationship?[10] These types of questions come up frequently in the healthcare system and the answers to all of these questions are usually far from clear but should be informed by medical ethics.

Shared decision making

Health advocacy messages such as this one encourage patients to talk with their doctors about their healthcare.

Shared decision making is the idea that as a patient gives informed consent to treatment, that patient also is given an opportunity to choose among the treatment options provided by the physician that is responsible for their healthcare. This means the doctor does not recommend what the patient should do, rather the patient's autonomy is respected and they choose what medical treatment they want to have done. A practice which is an alternative to this is for the doctor to make a person's health decisions without considering that person's treatment goals or having that person's input into the decision-making process is grossly unethical and against the idea of personal autonomy and freedom.

The spectrum of a physician’s inclusion of a patient into treatment decisions is well represented in Ulrich Beck’s World at Risk. At one end of this spectrum is Beck’s Negotiated Approach to risk communication, in which the communicator maintains an open dialogue with the patient and settles on a compromise on which both patient and physician agree. A majority of physicians employ a variation of this communication model to some degree, as it is only with this technique that a doctor can maintain the open cooperation of his or her patient. At the opposite end of this spectrum is the Technocratic Approach to risk communication, in which the physician exerts authoritarian control over the patient’s treatment and pushes the patient to accept the treatment plan with which they are presented in a paternalistic manner. This communication model places the physician in a position of omniscience and omnipotence over the patient and leaves little room for patient contribution to a treatment plan.[11]

Physician superiority

The physician may be viewed as superior to the patient simply because physicians tend to use big words and concepts to put him or herself in a position above the patient. The physician–patient relationship is also complicated by the patient's suffering (patient derives from the Latin patior, "suffer") and limited ability to relieve it on his or her own, potentially resulting in a state of desperation and dependency on the physician. A physician should be aware of these disparities in order to establish a good rapport and optimize communication with the patient. Additionally, having a clear perception of these disparities can go a long way to helping the patient in the future treatment. It may be further beneficial for the doctor–patient relationship to have a form of shared care with patient empowerment to take a major degree of responsibility for her or his care.

Those who go to a doctor typically do not know exact medical reasons of why they are there, which is why they go to a doctor in the first place. For a patient to not be able to understand what is going on with their body, because they can’t understand lab results or their doctor isn’t sharing or explaining them, can be a frightening and frustrating situation to be in. An in depth discussion of lab results and the certainty that the patient can understand them may lead to the patient feeling reassured, and with that may bring positive outcomes in the physician-patient relationship.

Benefiting or pleasing

A dilemma may arise in situations where determining the most efficient treatment, or encountering avoidance of treatment, creates a disagreement between the physician and the patient, for any number of reasons. In such cases, the physician needs strategies for presenting unfavorable treatment options or unwelcome information in a way that minimizes strain on the doctor–patient relationship while benefiting the patient's overall physical health and best interests. When the patient either can not or will not do what the physician knows is the correct course of treatment, the patient becomes non-adherent. Adherence management coaching becomes necessary to provide positive reinforcement of unpleasant options.

For example, according to a Scottish study,[12] patients want to be addressed by their first name more often than is currently the case. In this study, most of the patients either liked (223) or did not mind (175) being called by their first names. Only 77 individuals disliked being called by their first name, most of whom were aged over 65.[12] On the other hand, most patients do not want to call the doctor by his or her first name.[12]

Some familiarity with the doctor generally makes it easier for patients to talk about intimate issues such as sexual subjects, but for some patients, a very high degree of familiarity may make the patient reluctant to reveal such intimate issues.[13]

Transitional care

Transitions of patients between health care practitioners may decrease the quality of care in the time it takes to reestablish proper doctor–patient relationships. Generally, the doctor–patient relationship is facilitated by continuity of care in regard to attending personnel. Special strategies of integrated care may be required where multiple health care providers are involved, including horizontal integration (linking similar levels of care, e.g. multiprofessional teams) and vertical integration (linking different levels of care, e.g. primary, secondary and tertiary care).[14]

Turn-taking and conversational dominance

The process of turn-taking between health care professionals and the patients has a profound impact on the relationship between them. In most scenarios, a doctor will walk into the room in which the patient is being held and will ask a variety of questions involving the patient's history, examination, and diagnosis.[15] These are often the foundation of the relationship between the doctor and the patient as this interaction tends to be the first they have together. This can go a long way into impacting the future of the relationship throughout the patient's care. All speech acts between individuals seek to accomplish the same goal, sharing and exchanging information and meeting each participants conversational goals.[15]

Research carried out in medical scenarios analyzed 188 situations in which an interruption occurred between a physician and a patient. Of these 188 analyzed situations, research found that the doctor is much more likely (67% of the time, 126 occasions) as compared to the patient (33% of the time, 62 occasions).[15] This shows that physicians are practicing a form of conversational dominance in which they see themselves as far superior to the patient in terms of importance and knowledge and therefore dominate all aspects of the conversation. A question that comes to mind considering this is if interruptions hinder or improve the condition of the patient. Constant interruptions from the patient whilst the doctor is discussing treatment options and diagnoses can be detrimental or lead to less effective efforts in patient treatment. This is extremely important to take note of as it is something that can be addressed in quite a simple manner. This research conducted on doctor-patient interruptions also indicates that males are much more likely to interject out of turn in a conversation then women.[15] This can also lead to problems if a female physician is trying to convey messages as females statistically tend to interrupt in conversations less often than their male counterparts.[15]

Other involved individuals

An example of where other people present in a doctor–patient encounter may influence their communication is one or more parents present at a minor's visit to a doctor. These may provide psychological support for the patient, but in some cases it may compromise the doctor–patient confidentiality and inhibit the patient from disclosing uncomfortable or intimate subjects.

When visiting a health provider about sexual issues, having both partners of a couple present is often necessary, and is typically a good thing, but may also prevent the disclosure of certain subjects, and, according to one report, increases the stress level.[13]

Having family around when dealing with difficult medical circumstances or treatments can also lead to complications. Family members, in addition to the patient needing treatment may disagree on the treatment needing to be done. This can lead to tension and discomfort for the patient and the doctor, putting further strain on the relationship.

Bedside manner

The medical doctor, with a nurse by his side, is performing a blood test at a hospital in 1980.

A good bedside manner is typically one that reassures and comforts the patient while remaining honest about a diagnosis. Vocal tones, body language, openness, presence, honesty, and concealment of attitude may all affect bedside manner. Poor bedside manner leaves the patient feeling unsatisfied, worried, frightened, or alone. Bedside manner becomes difficult when a healthcare professional must explain an unfavorable diagnosis to the patient, while keeping the patient from being alarmed.

Dr. Rita Charon launched the narrative medicine movement in 2001 with an article in the Journal of the American Medical Association. In the article she claimed that better understanding the patient's narrative could lead to better medical care.[16]

Researchers and Ph.D.s in a BMC Medical Education journal conducted a recent study that resulted in five key conclusions about the needs of patients from their health care providers. First, patients want their providers to provide reassurance. Second, patients feel anxious asking their providers questions; they want their providers to tell them it’s ok to ask questions. Third, patients want to see their lab results and for the doctor to explain what they mean. Fourth, patients simply do not want to feel judged by their providers. And fifth, patients want to be participants in medical decision-making; they want providers to ask them what they want.[17]

An example of how body language affects patient perception of care is that the time spent with the patient in the emergency department is perceived as longer if the doctor sits down during the encounter.[18]

Examples in fiction

  • Dr. Gregory House (of the show House) has an acerbic, insensitive bedside manner. However, this is an extension of his normal personality.
  • In Grey's Anatomy, Dr. Burke compliments Dr. George O'Malley's ability to care for Dr. Bailey's baby by saying "it speaks to a good bedside manner."
  • Doc Martin from the Doc Martin British TV series is a good example of a physician with a bad bedside manner.
  • Dr Lily Chao from the British TV series Casualty is another example of a Foundation Doctor with a poor bedside manner, whereas her colleague, Dr Ethan Hardy has a better one.
  • In Lost, Hurley tells Jack Shephard that his bedside manner "sucks". Later in the episode, Jack is told by his father to put more hope into his sayings, which he does when operating on his future wife. The comments continue in other episodes of the series with Benjamin Linus sarcastically telling Jack that his "bedside manner leaves something to be desired" after Jack gives him a harsh negative diagnosis.
  • In Closer, Larry, the physician tells Anna when they first meet that he is famed for his bedside manner.
  • In Scrubs, J.D is presented as an example of a physician with great bedside manner, while Elliot Reid is a physician with bad or non-existent bedside manner at first, until she evolves during her tenure at Sacred Heart. Dr. Cox is an interesting subversion, in that his manner is brash and undiplomatic while still inspiring patients to do their own best to aid in the healing process, akin to a drill sergeant. This show also comically remarked that the most amount of time that a doctor needs to be in the presence of the patient before he finds out everything he needs to know is approximately 15 seconds.
  • In Star Trek: Voyager, the Doctor often compliments himself on the charming bedside manner he developed with the help of Kes.
  • In M*A*S*H, Hawkeye Pierce, Trapper John McIntyre, B.J. Hunnicutt, and Sherman Potter all possess a caring and humorous bedside manner meant to help patients cope with traumatic injuries. Charles Winchester initially possesses no real bedside manner, acting with detached professionalism, until the rigors of his job help him develop a sense of compassion for his patients. Frank Burns has a poor bedside manner, constantly minimizing the seriousness of his patients' injuries, accusing them of cowardice and goading them to return to the front lines.

Patient behavior

The behavior of the patient affects the doctor–patient relationship. Rude or aggressive behavior from patients or their family members can also distract healthcare professionals and cause them to be less effective or to make mistakes during a medical procedure. When dealing with situations in any healthcare setting, there is stress on the medical staff to do their job effectively. Whilst many factors can affect how their job gets done, rude patients and unappealing attitudes can play a big role. Research carried out by Dr. Pete Hamburger, associate dean for research at Tel Aviv University, evidences this fact. His research showed that rude and harsh attitudes shown toward the medical staff reduced their ability to effectively carry out some of their simpler and more procedural tasks. This is important because if the medical staff are not performing sufficiently in what should be simple tasks, their ability to work effectively in critical conditions will also be impaired.While it is completely understandable that patients are going through an extremely tough time compounded by stress from other external and internal factors, it is important for the doctors and medical staff to be wary of the rude attitudes that may come their way.[19][20]

See also

References

  1. ↑ Curran, James (1 November 2007). "The Doctor, his Patient and the Illness". BMJ. 335 (7626): 941–941. doi:10.1136/bmj.39384.467928.94. ISSN 0959-8138. PMC 2048858.
  2. ↑ "Balint in a nutshell" (PDF). International Balint Federation. February 2007. Archived from the original (PDF) on 4 March 2016. Retrieved 6 December 2015.
  3. ↑ "About Sir William Osler, his inspirational words, and the Osler Symposia for physicians". www.oslersymposia.org. Retrieved 19 October 2016.
  4. ↑ "The William Osler Papers: "Father of Modern Medicine": The Johns Hopkins School of Medicine, 1889-1905". profiles.nlm.nih.gov. Retrieved 19 October 2016.
  5. 1 2 Kelley JM, Kraft-Todd G, Schapira L, Kossowsky J, Riess H (2014). "The influence of the patient-clinician relationship on healthcare outcomes: a systematic review and meta-analysis of randomized controlled trials". PLOS ONE. 9 (4): e94207. doi:10.1371/journal.pone.0094207. PMC 3981763. PMID 24718585.
  6. ↑ "What to expect from your doctor: a guide for patients". General Medical Council. Retrieved 9 August 2014.
  7. ↑ "Press release: GMC publishes first guide for patients on what to expect from their doctor". General Medical Council. 22 April 2013. Archived from the original on 12 June 2013. Retrieved 9 August 2014.
  8. ↑ "Restructuring Informed Consent: Legal Therapy for the Doctor-Patient Relationship". The Yale Law Journal. 79 (8): 1533–1576. 1970. doi:10.2307/795271.
  9. ↑ Selinger, Christine P. (2009). "The right to consent: Is it absolute?". British Journal of Medical Practice. 2. 2: 50–54. Retrieved 5 March 2012.
  10. ↑ Lichtenberg, P.; Heresco-Levy, U.; Nitzan, U. (2004). "The ethics of the placebo in clinical practice". Journal of Medical Ethics. 30 (6): 551–554. doi:10.1136/jme.2002.002832. PMC 1733989. PMID 15574442.
  11. ↑ Beck, Ulrich. World at Risk. pp. 81–180.
  12. 1 2 3 McKinstry B (October 1990). "Should general practitioners call patients by their first names?". BMJ. 301 (6755): 795–6. doi:10.1136/bmj.301.6755.795. PMC 1663948. PMID 2224269.
  13. 1 2 Quilliam, Susan (April 2011). "'The Cringe Report': why patients don't dare ask questions, and what we can do about that". J Fam Plann Reprod Health Care. 37 (2): 110–112. doi:10.1136/jfprhc.2011.0060. PMID 21454267.
  14. ↑ Gröne, O & Garcia-Barbero, M (2002): Trends in Integrated Care – Reflections on Conceptual Issues. World Health Organization, Copenhagen, 2002, EUR/02/5037864
  15. 1 2 3 4 5 Brown, Peter J (1 January 1998). Understanding and applying medical anthropology. Mountain View, Calif.: Mayfield Pub. Co. ISBN 1559347236.
  16. ↑ Talan, Jamie (27 May 2003). "Storytelling for Doctors' Medical Schools Try Teaching Compassion by Having Students Write About Patients". Newsday.
  17. ↑ "BMC Medical Education". BMC Medical Education. Retrieved 5 May 2017.
  18. ↑ Simple Tips to Improve Patient Satisfaction By Michael Pulia. American Academy of Emergency Medicine. 2011;18(1):18–19.
  19. ↑ Klass, Perri (27 February 2017). "What Happens When Parents Are Rude in the Hospital". The New York Times. ISSN 0362-4331. Retrieved 2 March 2017.
  20. ↑ Riskin, Arieh; Erez, Amir; Foulk, Trevor A.; Riskin-Geuz, Kinneret S.; Ziv, Amitai; Sela, Rina; Pessach-Gelblum, Liat; Bamberger, Peter A. (1 February 2017). "Rudeness and Medical Team Performance". Pediatrics. 139 (2). doi:10.1542/peds.2016-2305. ISSN 1098-4275. PMID 28073958.

Further information

  • Alexander GC, Casalino LP, Meltzer DO (August 2003). "Patient-physician communication about out-of-pocket costs". JAMA. 290 (7): 953–8. doi:10.1001/jama.290.7.953. PMID 12928475.
  • Alexander GC, Casalino LP, Tseng CW, McFadden D, Meltzer DO (August 2004). "Barriers to patient-physician communication about out-of-pocket costs". J Gen Intern Med. 19 (8): 856–60. doi:10.1111/j.1525-1497.2004.30249.x. PMC 1492500. PMID 15242471.
  • Alexander GC, Casalino LP, Meltzer DO (March 2005). "Physician strategies to reduce patients' out-of-pocket prescription costs". Arch. Intern. Med. 165 (6): 633–6. doi:10.1001/archinte.165.6.633. PMID 15795338.
  • Alexander GC, Lantos JD (2006). "The doctor-patient relationship in the post-managed care era". Am J Bioeth. 6 (1): 29–32. doi:10.1080/15265160500394556. PMID 16423784.
  • Pham HH, Alexander GC, O'Malley AS (April 2007). "Physician consideration of patients' out-of-pocket costs in making common clinical decisions". Arch. Intern. Med. 167 (7): 663–8. doi:10.1001/archinte.167.7.663. PMID 17420424.
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