The doctor-patient relationship

The doctor-patient relationship is a central part of healthcare and the practice of medicine, forming one of the foundations of contemporary medical ethics.

It is a specific form of interpersonal relationship and, in the last years, has been the subject of many studies. The quality of the patient-physician relationship is important to both parties. A patient must have confidence in the competence of their physician and must feel that they can confide in the doctor, thus enhancing the accuracy of the diagnosis and increasing the patient’s knowledge about the disease.

For physicians, the establishment of good rapport with a patient is important.

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. Patients receive the best care when they work in partnership with doctors.

A good bedside manner is typically one that reassures and comforts the patient while remaining honest about a diagnosis. Vocal tone, body language, honest, and appropriate attitude may all affect bedside manner. Poor bedside manner leaves the patient feeling unsatisfied, worried, frightened or alone.

But please do not consider that a doctor with very good bedside manner is beyond any doubt the “best” doctor in his/her field.

Patient behaviour

The behaviour of the patient strongly affects the doctor-patient relationship. Rude or aggressive behaviour 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 is done, rude patients and unappealing attitudes can play a big role. Research carried out by Dr Pete Hamburger at Tel Aviv University showed that rude and harsh attitudes shown towards 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. It is completely understandable that patients are going through an extremely tough time due to several factors, but it is important for the doctors and medical staff to be wary of the rude attitudes that may come their way.

Doctor behaviour

The doctor-patient relationship has undergone a transition throughout the ages. Prior to the last two decades, the relationship was predominantly between a patient seeking help and a doctor whose decisions were silently complied with by the patient. In this paternalistic model, any information given to the patient is selected to encourage them to consent to the doctor’s decisions. This description of the asymmetrical, imbalanced interaction between doctor and patient has been challenged during the last 20 years, proposing a more active, autonomous and thus patient-centred role, with greater patient control, reduced physician dominance and more mutual participation.

This patient-centred approach has been described as one where “the physician tries to enter the patient’s world, to see the illness through the patient’s eyes”.

The patient is not just a group of symptoms, damaged organs and altered emotions; the patient is a human being, at the same time worried and hopeful, who is searching for relief, help and trust.

“To attend those who suffer, a physician must possess not only the scientific knowledge and technical abilities but also an understanding of human nature.”

Evolution of doctor-patient relationship

The Greeks with the Hippocratic Oath established a code of ethics for the doctors, whilst also providing a ‘Bill of Rights’ for the patient, raising medical ethics above the self-interests of class and status and providing a higher degree of humanism in dealing with the needs, wellbeing and interests of people.

The Hippocratic doctors considered an ethical requirement to follow the ‘criterion of beneficence’ as well as the principle ‘primum non nocere’ (first, to do no harm) which has become a core principle of medical ethics within the doctor-patient relationship.

Through the Renaissance and the French Revolution, the medical attitudes, actions and behaviours changed from an activity-passivity approach to a guidance-cooperation model.

Breuer and Freud (1955) began to constitute the patient as a person, meaning that it was of great importance to listen to the patient, developing a genuine communicative relationship and reintroducing the patient into the medical consultation as an active participant, leading to the creation of patient-centred medicine.

The doctor had become conscious or aware of the patient’s personality: “the patient was not simply an object but a person, needing enlightenment and reassurance”.

The report of the Planning Committee of the Royal College of Physicians on Medical Education regarded as essential that “from the beginning of his clinical career, the student should be encouraged to study his patient’s personality… just as he studies his patient’s physical signs and the data on the temperature chart”.

Szasz and Hollender (1956) proposed three basic models of the doctor-patient relationship. These are: active-passivity, guidance-cooperation and mutual participation. The first two models are entirely paternalistic and thus predominantly doctor-centred. The latter (mutual participation) has a greater emphasis on patient-centred medicine, currently practised today.

Patient-centred medicine

Over the last 20 years, an extensive body of literature has emerged that advocated the patient-centred approach to medical care. Patient-centred medicine regards the patient as a unique individual rather than the object of some disease or entity. Therefore, to develop a full understanding of the patient’s presentation and provide effective management, the doctor should strive to understand the patient as a distinctive personality within his own unique context.

Mead and Bower (2000) advocated a shift in the doctor-patient relationship from the ‘guidance-cooperation’ model to ‘mutual participation’ whereby power and responsibility are shared with the patient.

Patient-centred medicine is “two-person medicine”, whereby the doctor is an integral aspect of any such description: “the doctor and patient are influencing each other all the time and cannot be considered separately”.

Patient-centred consultations reflect recognition of patients’ needs and preferences, characterised by behaviours such as encouraging the patient to voice ideas, listening, reflecting and offering collaboration, leading to much greater patient-involvement in care.

The internet factor

Another contemporary effect on the doctor-patient relationship has been the exponential increase in the use of the internet by patients, which can be good … and bad!

Patients are generally better informed, especially in the more affluent countries of the West, facilitating the patient-centred approach to healthcare that predominates today. While better patient education has obvious advantages for the doctor-patient relationship, there are concerns as information on the internet might not always be accurate and reliable. This poses a new challenge for the medical professional; that of revising any misinformation the patient has found himself.

The doctor in the patient-centred model is ideally placed to bridge the gap between the world of medicine and the personal experiences and needs of his patients, thus sharing power and responsibility. Nevertheless, the patient has to understand and respect that the doctor has the technical skills, not him/her.

Many times, it is not easy for both sides!
“…one of the essential qualities of the clinicians is interest in humanity, for the secret of the care of patients is in caring for the patient”

Best health wishes,
Dr. Maria Alice

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Dr Maria Alice is a consultant in General and Family Medicine. General Manager/Medical Director – Luzdoc International Medical Service / Medilagos. Medical Director – Grupo Hospital Particular do Algarve