The Doctor–Patient Relationship

Overview

The doctor–patient relationship—despite all the pressures of accountable care, complex and demanding electronic health records, and other systemic complications—remains one of the most profound partnerships in the human experience; in it, one person reveals to another his or her innermost concerns, in hope of healing. In this deeply intimate relationship, when we earn our patients' trust, we are privileged to learn about fears and worries that our patients may not have shared—or ever will share—with another living soul; patients literally put their lives and well-being in our hands. For our part, we hope to bring to this relationship technical mastery of our craft, wisdom, experience, and humility as well as our physicianly commitment to stand by and with our patient—that is, not to be driven away by any degree of pain, suffering, ugliness, or even death itself. We foreswear our own gratification, beyond our professional satisfaction and reward, to place our patients' interests above our own. We hope to co-create a healing relationship, which Ventres and Frankel have elegantly termed “shared presence” in which our patients can come to understand with us the sources of suffering and the options for care and healing, and to partner with us in the construction of a path toward recovery.

In clinical medicine, the relationship between doctor and patient is not merely a vehicle through which to deliver care. Rather, it is one of the most important aspects of care itself. Excellent clinical outcomes—in which patients report high degrees of satisfaction, work effectively with their physicians, adhere to treatment regimens, experience improvements in the conditions of concern to them, and proactively manage their lives to promote health and wellness—are far more likely to arise from relationships with doctors that are collaborative and in which patients feel heard, understood, respected, and included in treatment planning. On the other hand, poor outcomes—including non-compliance with treatment plans, complaints to oversight boards, and malpractice actions—tend to arise when patients feel unheard, disrespected, or otherwise out of partnership with their doctors. Collaborative care not only leads to better outcomes but also is more efficient than non-collaborative care in achieving good outcomes. The relationship matters.

An effective doctor–patient relationship may be even more critical to successful outcomes in psychiatry than it is in other medical specialties. In psychiatry, more than in most branches of medicine, there is a sense that when the patient is ill, there is something wrong with the person as a whole, rather than that the person has, or suffers from, a discrete condition. Our language aggravates this sense of personal defectiveness or deficiency in psychiatric illness. We tend to speak of “being depressed” or “being bipolar” as if these are qualities of the whole person rather than a condition to be dealt with. Even more hurtfully, we sometimes speak of people as “borderlines” or “schizophrenics,” as if these labels sum up the person as a whole. This language, together with the persistent stigma attached to mental illness in our culture, amplifies the shame and humiliation that patients may experience in any doctor–patient interaction and makes it even more imperative that the physician works to create a safe relationship.

Moreover, if we seek to co-create a healing environment in which the patient feels understood, psychiatry more than any other branch of medicine requires us to attend thoughtfully to the whole person, even to parts of the person's life that may seem remote from the person's primary concern. This is especially salient in the general hospital, where a patient's medical problem may cause clinicians to overlook critically important aspects of the person's current relationships and social environment, from long-standing psychological issues, and from the person's spiritual orientation. Often, these psychological, social, or spiritual aspects shed light on the person's distress ( Figure 3-1 ). There must be time and space in the doctor–patient relationship to know the person from several perspectives: in the context of the person's biological ailments and vulnerabilities; in the setting of the person's current social connections, supports, and stressors; in the context of the person's earlier psychological issues; and in the face of the person's spirituality.

Unique Aspects of the Doctor–Patient Relationship in the General Hospital

In the general hospital, the doctor–patient relationship has several unique features. To begin with, a medical problem is usually the cornerstone of doctor–patient encounters. This simple fact has several key consequences.

First, the relationship occurs in the context of a complex interplay of psychiatric and medical symptoms and illnesses (see Figure 2-1 ) that may each stem from a variety of etiologies; the doctor–patient relationship must assess and attempt to address each of these domains.

Second, the dynamics of power and trust in the doctor–patient relationship may be different from those in outpatient settings. In the hospital, patients usually have not asked for a meeting with a psychiatrist, and may not welcome such a meeting. For instance, a psychiatrist may be called to evaluate a patient who is refusing treatment or who has developed hallucinations after a cholecystectomy. The context of care affects the patient's willingness and ability to engage in a relationship with a psychiatric physician. Doctors must be mindful of patient autonomy—which is typically strained by illness—and strive to maintain a patient-centered approach.

Third, the presence of a primary medical or surgical team changes a dyadic relationship into a complex doctor–patient–doctor triad. Both sets of physicians and the patient can feel pulled in different directions when there is disagreement about treatment. Physicians and patients alike tend to categorize illness and treatments as “medical” and “psychiatric.” Successful doctor–patient relationships collaborate in the service of patient care ( Figure 3-2 ).

Fourth, the hospital environment challenges privacy, space, and time and hinders the clinical encounter. For example, assessing whether a patient who is losing weight after a stroke is depressed may be especially difficult because of barriers to communication. The hospital roommate may have visitors who interrupt or inhibit the patient, or the patient may have intrinsic barriers to communication (e.g., an aphasia or intubation). Chapter 2 reviews some differences in approach, language, and style that may be applicable to care in the general hospital. Ultimately, regardless of setting, the doctor–patient relationship is at the core of the clinical encounter. The following sections will explore the provision of patient-centered care, conduct of the clinical interview, and creation of a clinical formulation and treatment plan; all of these are facilitated by a therapeutic doctor–patient relationship.

The Optimal Healing Environment: Patient-Centered Care

Although cultural factors limit the validity of this generalization, patients generally prefer care that centers on their own concerns; addresses their perspective on these concerns; uses language that is straightforward, is inclusive, and promotes collaboration; and respects the patient as a fully empowered partner in decision-making. This model of care may be denoted by the term patient-centered care or, even better, relationship-centered care . In Crossing the Quality Chasm , the Institute of Medicine identified person-centered practices as key to achieving high-quality care that focuses on the unique perspective, needs, values, and preferences of the individual patient. Person-centered care involves a collaborative relationship in which two experts—the practitioner and the patient—attempt to blend the practitioner's knowledge and experience with the patient's unique perspective, needs, and assessment of outcome.

In relationship-centered practice, the physician does not cede decision-making authority or responsibility to the patient and family but rather enters into a dialogue about what the physician thinks is best. Most patients and families seek a valued doctor's answer to the question (stated or not), “What would you do if this were your family member?” This transparent and candid collaboration conveys respect and concern. Enhanced autonomy involves a commitment to know the patient deeply, to respect the patient's wishes, to share information openly and honestly (as the patient desires), to involve others at the patient's discretion, and to treat the patient as a partner (to the greatest extent possible).

In patient-centered care, there is active management of communication to avoid inadvertently hurting, shaming, or humiliating the patient through careless use of language or other slights. When such hurt or other error occurs, the practitioner apologizes clearly and in a heartfelt way to restore the relationship.

The role of the physician in patient-centered care is one of an expert who seeks to help a patient co-manage his or her health to whatever extent is most comfortable for that particular person. The role is not to cede all important decisions to the patient.

The patient-centered physician attempts to accomplish six goals ( Table 3-1 ). First, the physician endeavors to create conditions of welcome, respect, and safety so that the patient can reveal his or her concerns and perspective. Second, the physician endeavors to understand the patient as a whole person, listening to both the “lyrics” and the “music” of what is communicated. Third, the physician confirms and demonstrates his or her understanding through direct, non-jargonistic language to the patient. Fourth, if the physician successfully establishes common ground on the nature of the problem as the patient perceives it, an attempt is made to synthesize these problems into workable diagnoses and problem lists. Fifth, through the use of technical mastery and experience, a path is envisioned toward healing, and it is shared with the patient. Finally, together, the physician and patient can then negotiate the path that makes the most sense for this particular patient.

Through all of this work, the physician models and cultivates a relationship that values candor, collaboration, and authenticity; it should be able to withstand and even welcome conflict, as a healthy part of human relationships. In so doing, the physician–patient partnership forges a relationship that can withstand the vicissitudes of the patient's illness, its treatment, and conflict in the relationship itself. In this way, the health of the physician–patient relationship takes its place as an important element on every problem list, to be actively monitored and nurtured as time passes.