Question

Discuss the intricacies of the doctor- patient relationship, and 4 of the major problems/issues that do or could arise.

Answer 1

Trust, knowledge, regard, and loyalty are the 4 elements that form the doctor-patient relationship, and the nature of this relationship has an impact on patient outcomes.

■ Factors affecting the doctor-patient relationship can be patient-dependent, provider-dependent, health system–dependent, or due to patient-provider mismatch.

■ Solutions to each of these factors are rooted in the 4 elements of the doctor-patient relationship.

Have you ever wondered what makes the doctor-patient relationship so powerful? Have you ever considered what you could do to strengthen it or to prevent it from crumbling? Have you thought about the consequences of unsatisfactory or adversarial relationships? If you have, then the following case vignettes and discussion should prove useful.

CASE VIGNETTE 1

Mr A, a 43-year-old man with a 20-year history of intravenous drug abuse (complicated by hepatitis C and recurrent abscesses), was admitted to the hospital for treatment of acute bacterial endocarditis. His inpatient medical team consulted the addictions consult/substance abuse team, who evaluated and enrolled him in an outpatient methadone clinic. Mr A noted that prior to this assessment he had never had a “decent” conversation about addiction treatment.

CASE VIGNETTE 2

Ms B, a 75-year-old woman with an alcohol use disorder and gastroesophageal reflux disorder, presented to the oncology clinic following her new (incidental) diagnosis of gastric carcinoma. During the visit, the oncologist explained the importance of assessing the depth of the tumor’s invasion into the gastric wall (ie, to stage the tumor and to decide on treatment options). He noted that if the tumor was confined to the most superficial layer of the stomach, it could be excised during an endoscopy. If the tumor went deeper, Ms B would need radiation and/or chemotherapy or surgery. The oncologist arranged for an immediate visit by the surgeon, who informed her that the cancer would almost certainly be invasive and that he planned to remove a large part of her stomach. He described her surgery as very serious, but necessary, because her cancer was very likely to lead to death. As the surgeon turned to write his note in the electronic medical record, Ms B began to shake her head from side to side and cry.

WHY IS THE DOCTOR-PATIENT RELATIONSHIP SO IMPORTANT?

The doctor-patient relationship involves vulnerability and trust. It is one of the most moving and meaningful experiences shared by human beings. However, this relationship and the encounters that flow from it are not always perfect.

The doctor-patient relationship has been defined as “a consensual relationship in which the patient knowingly seeks the physician’s assistance and in which the physician knowingly accepts the person as a patient.”1(p6) At its core, the doctor-patient relationship represents a fiduciary relationship in which, by entering into the relationship, the physician agrees to respect the patient’s autonomy, maintain confidentiality, explain treatment options, obtain informed consent, provide the highest standard of care, and commit not to abandon the patient without giving him or her adequate time to find a new doctor. However, such a contractual definition fails to portray the immense and profound nature of the doctor-patient relationship. Patients sometimes reveal secrets, worries, and fears to physicians that they have not yet disclosed to friends or family members. Placing trust in a doctor helps them maintain or regain their health and well-being.

This unique relationship encompasses 4 key elements: mutual knowledge, trust, loyalty, and regard.2 Knowledge refers to the doctor’s knowledge of the patient as well as the patient’s knowledge of the doctor. Trust involves the patient’s faith in the doctor’s competence and caring, as well as the doctor’s trust in the patient and his or her beliefs and report of symptoms. Loyalty refers to the patient’s willingness to forgive a doctor for any inconvenience or mistake and the doctor’s commitment not to abandon a patient. Regard implies that the patients feel as though the doctor likes them as individuals and is “on their side.” These 4 elements constitute the foundation of the doctor-patient relationship.

WHAT IS THE STRUCTURE OF THE DOCTOR-PATIENT RELATIONSHIP?

In their seminal article from 1956, Szasz and Hollender3 outlined 3 basic models of the doctor-patient relationship.

Active-Passive Model

The active-passive model is the oldest of the 3 models. It is based on the physician acting upon the patient, who is treated as an inanimate object. This model may be appropriate during an emergency when the patient may be unconscious or when a delay in treatment may cause irreparable harm. In such situations, consent (and complicated conversations) is waived.

Guidance-Cooperation Model

In the guidance-cooperation model, a doctor is placed in a position of power due to having medical knowledge that the patient lacks. The doctor is expected to decide what is in the patient’s best interest and to make recommendations accordingly. The patient is then expected to comply with these recommendations.

Mutual Participation Model

The mutual participation model is based on an equal partnership between the doctor and the patient. The patient is viewed as an expert in his or her life experiences and goals, making patient involvement essential for designing treatment. The physician’s role is to elicit a patient’s goals and to help achieve these goals. This model requires that both parties have equal power, are mutually interdependent, and engage in activities that are equally satisfying to both parties.

While each of these models may be appropriate in specific situations, over the last several decades there has been increasing support for the mutual participation model whenever it is medically feasible.

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