Doctor–patient relationship

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The doctor–patient relationship is a central part of health care and the practice of medicine. A doctor–patient relationship is formed when a doctor attends to a patient's medical needs and is usually through consent.^[1] This relationship is built on trust, respect, communication, and a common understanding of both the doctor and patients' sides. The trust aspect of this relationship goes is mutual: the doctor trusts the patient to reveal any information that may be relevant to the case, and in turn, the patient trusts the doctor to respect their privacy and not disclose this information to outside parties.

A ceremonial dynamic of the doctor–patient relationship is that the doctor is encouraged by oath to follow certain ethical guidelines. (Hippocratic Oath) ^[2][3] Additionally, the healthiness of a doctor–patient relationship is essential to keep the quality of the patient's healthcare high as well as to ensure that the doctor is functioning at their optimum. In more recent times, healthcare has become more patient-centered and this has brought a new dynamic to this ancient relationship.^{[citation needed]}

Importance

A patient must have confidence in the competence of their physician and must feel that they can confide in them. 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 may lead to frequent, freely-offered quality information about the patient's disease and as a result, better healthcare for the patient and their family. Enhancing both the accuracy of the diagnosis and the patient's knowledge about the disease contributes to a good relationship between the doctor and the patient.

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.^[13] There can be issues with how to handle informed consent in a doctor–patient relationship;^[14] 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?^[15] 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

Shared decision-making involves both the doctor and patient being involved in decisions about treatment. There are varied perspective on what shared decision making involves, but the most commonly used definition involves the sharing of information by both parties, both parties taking steps to build consensus, and reaching an agreement about treatment.^[16]: 4

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. An alternative practice, 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 considered 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.^[17]

Physician communication style

Physician communication style is crucial to the quality and strength of the doctor–patient relationship. Patient-centered communication, which involves asking open-ended questions, having a warm disposition, encouraging emotional expression, and demonstrating interest in the patient's life, has been shown to positively affect the doctor–patient relationship. Additionally, this type of communication has been shown to decrease other negative attitudes or assumptions the patient might have about doctors or healthcare as a whole, and has even been shown to improve treatment compliance.^[18] Another form of communication beneficial to the patient-provider relationship is self-disclosure by the physician in particular. Historically, medical teaching institutions have discouraged physicians from disclosing personal or emotional information to patients, as neutrality and professionalism were prioritized. However, self-disclosure by physicians has been shown to increase rapport, the patient's trust, their intention to disclose information, and the patient's desire to continue with the physician. These effects were shown to be associated with empathy, which is another important dimension which is often under-emphasized in physician training.^[19] A physician's response to emotional expression by their patient can also determine the quality of the relationship, and influence how comfortable patients are in discussing sensitive issues, feelings, or information that may be critical for their diagnosis or care. More passive, neutral response styles which allow for patients to elaborate on their feelings have been shown to be more beneficial for patients, and make them feel more comfortable. Physician avoidance or dismissal of a patient's emotional expression may discourage the patient from opening up, and may be harmful to their relationship with their provider.^[20][21]

Physician superiority

Historically, in the paternalistic model, a physician tended to be viewed as dominant or superior to the patient due to the inherent power dynamic of physician's control over the patient's health, treatment course, and access to knowledge about their condition. In this model, physicians tended to convey only the information necessary to convince the patient of their proposed treatment course. The physician–patient relationship is also complicated by the patient's

Patients who seek a doctor's help typically do not know or understand the medical science behind their condition, which is why they go to a doctor in the first place. A patient with no medical or scientific background may not be able to understand what is going on with their body without their doctor explaining it to them. As a result, this can be a frightening and frustrating experience, filled with a sense of powerlessness and uncertainty for the patient,[22]^[23] though in rare conditions, this pattern tends not to be followed, and due to lack of expertise patients are forced to learn about their conditions.^[24]: 155

An in-depth discussion of diagnosis, lab results, and treatment options and outcomes in layman's terms that the patient can understand can be reassuring and give the patient a sense of agency over their condition. Concurrently, this type of strong communication between a doctor and their patient can strengthen the physician–patient relationship as well as promote better treatment adherence and health outcomes.^[22][23]

Coercion

Under certain conditions healthcare workers are able to treat patients involuntarily, imprison them, or involuntarily administer drugs to alter the patients' ability to think. They may also engage in forms of "informal coercion" where information or access to social services can be used to control a patient.

Deception

Lying in the doctor–patient relationship is common.^[25]: 164 Doctors provide minimal information to patients after medical errors. Doctors may lie to patients to displace culpability for poor outcomes and say they avoid giving patients information because it may confuse patients, cause pain, or undermine hope. They may lie to avoid uncomfortable conversation about disability or death, or to encourage patients to accept a particular treatment option.^[25]: 165 The experience of being lied to may undermine an individual's trust in others or themselves and reduce faith in one's church, community or society and result in avoidant behaviour to avoid being wounded. Patients may seek financial and legal retribution.^[25]: 166

Patients may lie to doctors for financial reasons such as to receive

Palmeira and Sterne offer different psychological framings and motivations for lying. From the perspective of attachment theory, lying may be used to avoid revealing information about an individual, to avoid intimacy and therefore the risk of rejection or shame, or to exaggerate to obtain protection or care. They also discuss the idea of protecting or maintaining an ego ideal.^[25]: 165Generally, Palmeira and Sterne suggestion discussions about the amount of information and detail parties wish to discuss, viewing obtaining truth as an ongoing process to increase truthfulness in doctor–patient interactions. Palmeira and Sterne suggest that physicians acknowledge their lack of knowledge, and discuss the amount of detail they wish to discuss to avoid deception.^[25]: 167

Physician bias

Physicians have a tendency of overestimating their communication skills,^[26] as well as the amount of information they provide their patients.^[27] Extensive research conducted on 700 orthopedic surgeons and 807 patients, for instance, found that 75% of the surgeons perceived they satisfactorily communicated with their patients, whereas only 21% of the patients were actually satisfied with their communication.^[28] Physicians also show a high likelihood of underestimating their patients' information needs and desires, especially for patients who were not college educated or from economically disadvantaged backgrounds.^[29][30] There is pervasive evidence that patients' personal attributes such as age, sex, and socioeconomic status may influence how informative physicians are with their patients.^[29][30] Patients who are better educated and from upper or upper middle-class positions generally receive higher quality and quantity of information from physicians than do those toward the other end of the social spectrum, although both sides have an equal desire for information.^[30]

Race, ethnicity and language has consistently proven to have a significant impact on how physicians perceive and interact with patients.^[31] According to a study of 618 medical encounters between mainly Caucasian physicians and Caucasian and African American patients, physicians perceived African Americans to be less intelligent and educated, less likely to be interested in an active lifestyle, and more likely to have substance abuse problems than Caucasians.^[32] A study of patients of color showed that having a white physician led to increased experience of microaggressions.^[33] Studies in Los Angeles emergency departments have found that Hispanic males and African Americans were less than half as likely to receive pain medication than Caucasians, despite physicians' estimates that patients were experiencing an equivalent level of pain.^[31] Another study showed that ethnic-minority groups of varying races reported lower-quality healthcare experiences than non-Hispanic Whites, specifically in treatment decision involvement and information received regarding medications.^[34] Other studies show that physicians exhibited substantially less rapport building and empathetic behavior with both Black and Hispanic patients than Caucasians, despite the absence of language barriers.^[31][18][21]

Medical mistrust

Medical mistrust has been shown to be greater for minority group patients, and is associated with decreased compliance, which can contribute to poorer health outcomes. Research of breast cancer patients showed that African American women who received concerning mammogram results were less likely to discuss this with their doctor if they had greater medical mistrust.^[37] Another study showed that women with higher physician mistrust waited longer to report symptoms to a doctor and receive a diagnosis of ovarian cancer.^[38] Two studies showed that African American patients had more medical mistrust than white patients, and were less likely to undergo a recommended surgery as a result.^[35][36]

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.

For example, according to a Scottish study,^[39] 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.^[39] On the other hand, most patients do not want to call the doctor by his or her first name.^[39]

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.^[40]

Transitional care

Researchers have studied the doctor–patient relationship using the theory of conversation analysis.^[42] One of the key concepts in conversation analysis is turn-taking. 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.^[43] 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.^[43]

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).^[43] 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 than women.^[43] Men's social predisposition to interject becomes problematic when it negatively impacts a woman physician's messages to her patients who are men: she may not be able to finish her statements and the patient will not benefit from what she was about to say, and the physician herself may fall prey to the socially conventional man's interjection by letting it cut short her professional commentary. Conversely, men physicians need to encourage women patients to articulate their reactions and questions, since women interrupt in conversations statistically less often than men do.^[43]

A hurdle can arise from how the thinking process goes: a patient typically relates their story in chronological order, where symptoms, test results, consulting opinions, diagnoses and treatment are intertwined. A provider tends to design their approach in a step-by-step analytical manner, extracting as much details out of symptomatology, then past medical and social history then tests then coming to a suggested diagnosis and management plan. Addressing this upfront and at the onset of the visit and carving enough time for both can help avoid unnecessary interruptions on either part, improve provider-patient relation and constructively facilitate care.

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.^[40]

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.

Telehealth

With the extensive use of technology in healthcare, a new dynamic has risen in this relationship. Telehealth is the use of telecommunications and/or electronic information to support a patient.^[44] This applies to clinical care, health-related education, and health administration.^[45] An important fact about telehealth is that it increases the quality of the doctor–patient relationship by making health resources more easily available, affordable, and more convenient for both parties. Challenges with using telehealth are that it is harder to get reimbursements, to acquire cross-state licensure, to have common standards, maintain privacy, and have proper guiding principles.^[44] The types of care that can be provided via telehealth include general health care (wellness visits), prescriptions for medicine, dermatology, eye exams, nutrition counseling, and mental health counseling. Just like with an in-person visit, it is important to prepare for a telehealth consultation beforehand and have good communication with the healthcare provider.^[46]

An interesting outcome of telehealth is that doctors have started to play a different role in the relationship. With patients having more access to information, medical knowledge, and their health data; doctors play the role of a translator between technical data and the patients. This has caused a shift in the way that the doctors see themselves concerning the doctor–patient relationship. Doctors who are engaged in telehealth see themselves as a guide to the patient and undertake the role of a guardian and information manager in the description, collection, and sharing of their patient's data. This is the new dynamic that has risen in this ancient relationship and one which will continue to evolve.^[47]

Bedside manner

• 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

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 is okay 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.[49]

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.^[50]

Patient behavior

Rude behaviour by patients can have a negative effect on medical outcomes. A study showed that staff who received or witnessed rude behaviour by patients relatives had reduced 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. This is consistent with research showing that rudness by medical staff to one another decreases effectiveness.^[51][52]

Examples in fiction

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• 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 Ethan Hardy
  has a better one.
• In
  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
  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 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
  the Doctor often compliments himself on the charming bedside manner he developed with the help of Kes
  .
• In
  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.

See also

• Aggression in healthcare
• Bullying in medicine
• Doctor–patient confidentiality
• Duty of candor
• Medical ethics
• Medical malpractice
• Patient abuse
• Physician
• Professional boundaries
• Patients' Welfare Association

References

1. ^ "Patient-Physician Relationships". American Medical Association. Retrieved 15 December 2020.
2. ^ Dwolatzky, T., Dwolatzky, Clarfield, A. M., & Clarfield. (2006). Doctor-Patient Relationships. In R. Schulz, Encyclopedia of aging (4th ed.). Springer Publishing Company. Credo Reference: https://go.openathens.net/redirector/palmbeachstate.edu?url=https%3A%2F%2Fsearch.credoreference.com%2Fcontent%2Fentry%2Fspencage%2Fdoctor_patient_relationships%2F0%3FinstitutionId%3D6086.
3. ^ Browning, P. E. (2018). Professional Patient relationship. In J. L. Longe (Ed.), Gale virtual reference library: The Gale encyclopedia of nursing and allied health (4th ed.). Gale. Credo Reference: https://go.openathens.net/redirector/palmbeachstate.edu?url=https%3A%2F%2Fsearch.credoreference.com%2Fcontent%2Fentry%2Fgalegnaah%2Fprofessional_patient_relationship%2F0%3FinstitutionId%3D6086.
4. PMID 9933492
   .
5. ISBN 978-1-315-66403-3
   , retrieved 14 April 2021
6. PMC 2048858
   .
7. ^ "Balint in a nutshell" (PDF). International Balint Federation. February 2007. Archived from the original (PDF) on 4 March 2016. Retrieved 6 December 2015.
8. ^ "About Sir William Osler, his inspirational words, and the Osler Symposia for physicians". www.oslersymposia.org. Archived from the original on 27 October 2017. Retrieved 19 October 2016.
9. ^ "The William Osler Papers: "Father of Modern Medicine": The Johns Hopkins School of Medicine, 1889-1905". profiles.nlm.nih.gov. Retrieved 19 October 2016.
10. ^
    PMID 24718585
    .
11. ^ "What to expect from your doctor: a guide for patients". General Medical Council. Retrieved 9 August 2014.
12. ^ "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.
13. JSTOR 795271
    .
14. ^ Selinger, Christine P. (2009). "The right to consent: Is it absolute?". British Journal of Medical Practice. 2. 2: 50–54. Retrieved 5 March 2012.
15. PMID 15574442
    .
16. ISBN 978-0-19-954627-5
    .
17. ^ Beck, Ulrich. World at Risk. pp. 81–180.
18. ^
    ISSN 0732-183X
    .
19. S2CID 162180521
    .
20. PMID 21784600
    .
21. ^
    PMID 32253063
    .
22. ^
    PMID 17386916
    .
23. ^
    PMID 1556799
    .
24. PMID 22464590
    .
25. ^
    PMID 19750068
    .
26. PMID 21603354
    .
27. PMID 4031436
    .
28. ProQuest 205141459
    .
29. ^
    S2CID 28640847
    .
30. ^
    PMID 6481931
    .
31. ^
    PMID 12038717
    .
32. PMID 10695979
    .
33. S2CID 20954812
    .
34. S2CID 129942732
    .
35. ^
    S2CID 84843736
    .
36. ^
    PMID 31965527
    .
37. PMID 30285074
    .
38. PMID 31415710
    .
39. ^
    PMID 2224269
    .
40. ^
    PMID 21454267. Archived from the original
    on 13 May 2013. Retrieved 8 July 2011.
41. ^ Gröne, O & Garcia-Barbero, M (2002): Trends in Integrated Care – Reflections on Conceptual Issues. World Health Organization, Copenhagen, 2002, EUR/02/5037864
42. S2CID 11983475
    .
43. ^
    OCLC 37442599
    .
44. ^ ^{a b} Romano, C. A., & Seckman, C. A. (2011). Telehealth. In H. R. Feldman, Nursing leadership (2nd ed.). Springer Publishing Company. Credo Reference: https://go.openathens.net/redirector/palmbeachstate.edu?url=https%3A%2F%2Fsearch.credoreference.com%2Fcontent%2Fentry%2Fspnurld%2Ftelehealth%2F0%3FinstitutionId%3D6086.
45. ^ Whitten, P. (2014). Telemedicine. In T. L. Thompson, & T. L. Thompson (Eds.), Encyclopedia of health communication. Sage Publications. Credo Reference: https://go.openathens.net/redirector/palmbeachstate.edu?url=https%3A%2F%2Fsearch.credoreference.com%2Fcontent%2Fentry%2Fsageheltcomi%2Ftelemedicine%2F0%3FinstitutionId%3D6086.
46. ^ "Telehealth". medlineplus.gov. Retrieved 15 December 2020.
47. PMID 32986733
    .
48. ^ Talan, Jamie (27 May 2003). "Storytelling for Doctors' Medical Schools Try Teaching Compassion by Having Students Write About Patients". Newsday.
49. PMID 28148254. {{cite journal}}: Cite journal requires |journal= (help
    )
50. ^ Simple Tips to Improve Patient Satisfaction By Michael Pulia. American Academy of Emergency Medicine. 2011;18(1):18–19.
51. ISSN 0362-4331
    . Retrieved 2 March 2017.
52. 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.
  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.
  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.
  PMID 15795338
  .
• Alexander GC, Lantos JD (2006). "The doctor-patient relationship in the post-managed care era". Am J Bioeth. 6 (1): 29–32.
  S2CID 8019757
  .
• 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.
  PMID 17420424
  .

External links

Look up bedside manner in Wiktionary, the free dictionary.

• Report of a large summit of patients and physicians, where the ideal patient-physician relationship in the 21st century was discussed. Organised by Johns Hopkins and American Healthways in 2003
• Haig, Scott (November 8, 2007). "When the patient is a Googler". Time.
  • Mary Shomon's November 13, 2007, response
  • Mary Shomon's November 13, 2007, further response
  • Trisha Torrey's November 24, 2007, response