Doctor-patient relationship

Doctor-patient relationship. The doctor-patient relationship in a historical setting is dependent on the medical situation and the social scene, that is, the socio-political and intellectual climate at the time. Here is a time-line showing the evolution of the doctor-patient relationship in our part of the world. In ancient Egypt, doctors were as much magicians and priests as they were healers, and the relationship was very much doctor-dominated and the patient was passive. The Greeks abandoned magical and religious beliefs of disease and introduced a more democratic form of social organisation which in turn led to a doctor and patient relationship characterized by mutual participation and guided cooperation. In medieval Europe and inquisition period, the restoration of religious and supernatural beliefs led to a regression of the doctor-patient relationship where the doctor was again filled with magical powers over a passive patient. During the French Revolution the social struggles changed medical attitudes taking the doctor-patient relationship once again towards a model of guided cooperation. In the 18th Century hospitals emerged as places to treat the underprivileged and the biomedical model of illness developed requiring the examination of the patient’s body and the expert clinical and anatomical knowledge possessed by the doctor. This gave way to a more paternalistic doctor-patient relationship. The advent of psychoanalytical and psychosocial theories in the late 1800’s allowed for the development of a genuine communicative relationship, with the patient being an active participant. In the mid 1950’s the Americans, Szasz and Hollander proposed three models of doctor-patient relationship: Activity/passivity, (emergency situations), Guidance cooperation (less acute situations), mutual participation (doctor helps patient to help herself) Balint in 1964 introduced the concept of “doctor as a drug” emphasizing the dynamic nature of the doctor/patient relationship. In the last 40 years the burst of scientific and technological breakthroughs has favoured a disease-centred approach which is also inevitably a physician centred approach but fortunately research into patient centeredness has and is continuing. Recently, doctor patient relationship has been challenged by complex and multiple factors occurring in our society such as the advent of internet and the accessibility to medical knowledge. So that a new challenge for the medical profession is to revise any misinformation the patient may have found. Another factor is the “marketisation” of society which leads to a more aggressive individualism. In this context the patient has become the customer or consumer who views the care provided by the NHS as services. This has led to a subtle shift in the power relationship between doctors and patients. The next factor is the misleading messages of the media which find doctors having to face the common opinion that adverse medical outcomes are necessarily unacceptable consequences of malpractice. Also the increased medical negligence claims are responsible for the erosion of the doctor-patient relationship which bring about high levels of mutual distrust, patients seeking a second opinion and adversarial relationships. Another point is the more egalitarian relationship between doctor and patient facilitating the emergence of the notion of partnership and shared decision making. This brings about the need for the expansion of higher order clinical communication skills such as negotiation and shared management planning. Moreover, the traditional individual role of the doctor has shifted towards increasingly collaborative working practices of the multiprofessional health-care team which leads to the need for the acquisition of communication skills needed for successful team work. Lastly, cultural diversity calls for the development of flexible and culturally sensitive communication styles. The key of any good relationship is communication. And in fact, effective doctor/patient communication has been reported to improve patient’s health outcomes, patient’s compliance to treatment, patient’s satisfaction with the medical encounter and patient’s recall and understanding. With regard to patient’s health outcomes, the author considered randomized controlled trials in which patients health was an outcome/variable from Medline database and he found that effective communication exerts a positive influence, not only on the emotional health, but also on symptoms resolution, functional and physiological status and pain control. Effective Doctor/patient communication, on the other hand, has been reported to decrease physiological distress and the likelihood of mistakes and malpractice litigations. To this regard, it has been demonstrated that mistakes by clinicians do not usually result from not caring enough about the patient’s welfare, but rather from a variety of other factors, such as, time lag in communicating the information or simple miscommunication or yet still physicians saying one thing, and a nurse understanding another. And these are all communication problems. In 1986 it was reported that lawsuits were filed because of physician-communication problems in 35% of the cases and the physicians’ attitude in another 35%, which altogether totals 70%. Along this line, in 1994 it was reported that pure communication and attitudes were the reasons for litigation against doctors in 70% of cases. In 1997, it was found that communication problems are significant factors in malpractice claims with the patients feeling devalued in 29%, neglected 32%, not understood 13%, misinformed 26%. It has also been reported that communication and interaction skills have the most impact on the patient’s motivation to litigate in the face of disappointing outcomes. On the other hand, clinicians skilled in interacting can do a great deal to reduce their risk of being sued. Since doctors usually like to be both responsible and successful, and no one wants to get sued, it is important to be aware that good communication may reduce the likelihood of errors, due to better information, for example, by listening carefully to the patient and communicating properly with other members of the staff and the likelihood of claims regardless of the quality of care. All this, should in the end result fewer malpractice suits. From what we have seen, the proven benefits of an effective doctor/patient communication represent a clear evidence-base for teaching clinical communication skills. As a matter of fact doctors who had not undertaken any communication skills training were unable to demonstrate important basic communication skills, even after 10 years or more of post registration clinical work. Whereas in another study, medical students who had received clinical communication skills training had a rich conceptualisation of communication and felt that training had helped them to understand their patient’s needs. For all these reasons nowadays clinical communication skills should be viewed as representing a “need to know” rather than a ”nice to know” component of our OBGYN training in order to reach our main goal which is to achieve a effective therapeutic alliance. This is the reason why in your logbook for postgraduate training and assessment in OBGYN among the skills which need to be assessed, you find: relation with patients and relations with medical and other staff. At this point I would like close my presentation with a short story by Schopenhauer about a group of hedgehogs which clearly illustrates the development of a good interpersonal relationship.