Overview
This session introduces the doctor-patient relationship as central to clinical practice: it frames the relationship historically and philosophically, sets out the many aspects that make it up, presents survey data on which qualities patients value most, links communication style to patient outcomes, and situates the relationship within a nested model of professionalism and ethics, shaped on both sides by personal and contextual factors including the doctor’s own self-knowledge.
Learning outcomes for the session
- Develop an awareness of the central role of the patient-doctor relationship in clinical medicine.
- Identify some of the many aspects of the patient-doctor relationship.
- Reflect on the judgements made about other people.
- Reflect on your own aptitudes, attitudes and skills that may be important over the next five years as you develop your consultation skills.
Historical framing of the relationship
Plato is credited with the idea that the best clinical medicine is practised when scientific knowledge is combined with a personal, trusting, professional relationship between doctor and patient. Peabody, addressing Harvard medical students in 1925, extended this: the treatment of a disease may be entirely impersonal, but the care of a patient must be completely personal. He held that in an extraordinarily large number of cases, both diagnosis and treatment directly depend on this intimate personal relationship, and that a young physician’s failure to establish it accounts for much of his ineffectiveness in caring for patients (Dugdale et al, 2008).
Aspects of the doctor-patient relationship
- Building trust: the patient’s and whanau’s wishes, aspirations, fears, anxieties, beliefs, religion, preconceptions etc.
- Avoiding negative stereotypes and judgements, by getting to know the patient’s and whanau’s history and context (“walking in their shoes”).
- Choosing the most effective channels of communication and language skills.
- Cultural competence and cultural safety.
- Legal aspects: patient rights, mental capacity, ACC etc.
- Ethical aspects: what is right in this situation?
- Exploration of management options, including affordability.
What patients value most in their doctor
Survey data (Figure 3) ranked 26 professional qualities by how often participants placed them in their top five. In descending order of frequency, the qualities ranked highest were: is honest with you, listens carefully, treats you with respect, is competent, gives understandable information, keeps up to date, is trustworthy, involves you in decisions, maintains confidentiality, and has good personal hygiene. Lower down the ranking (in order) were: is friendly, is reasonably available, shows understanding, shows empathy, is knowledgeable, explains things well, is effective, takes their time, respects your ideas, communication skills, puts your needs first, is open-minded, is thorough, has a sense of humour, improves community health, and has integrity.
The percentages behind this ranking were estimated by eye from bar lengths on the chart rather than read from exact data labels. Treat the order above as the reliable finding; treat any specific percentage as approximate only.
Communication and patient outcomes
Physicians who are informative, show support and respect for the patient, and facilitate patient participation in care generally have patients who are more satisfied, more committed to their treatment regimens, and who experience better health following the consultation (Street et al, 2007).
The doctor-patient context model
The relationship is shown as a nested model: an outer “Professionalism” layer contains “Ethics”, and within Ethics sits the Patient <-> Doctor relationship itself, drawn as a two-way (reciprocal) connection. Reading the nesting as content: professionalism is the broad context within which ethics operates, and the reciprocal patient-doctor relationship sits within that ethical space.
Both parties are shaped by parallel personal and contextual factors:
- Patient factors: personality, culture and beliefs, immediate context, past experiences, past relationships, illness.
- Doctor factors: personality, culture and beliefs, immediate context, past experiences, past relationships, skills and knowledge.
The two lists are identical except for the final factor: for the patient it is illness, while for the doctor it is skills and knowledge.
The doctor’s self-knowledge
Entering the patient’s world and seeing the illness through that person’s eyes is described as a difficult task requiring, above all, self-knowledge as the most crucial attribute. The doctor is said to be inevitably influenced by their own personal and cultural background and values, life experiences, beliefs and prejudices, educational and professional status, perception of the role of the physician and of the individual patient, and the positive or negative feelings and emotional responses the patient evokes in them (Polliak, 1992).
Self-test
- State the four learning outcomes for this session.
- According to Peabody (1925), why does the personal relationship between physician and patient matter for diagnosis and treatment, and what did he say explains a young physician’s ineffectiveness?
- List the aspects of the doctor-patient relationship identified in the lecture.
- According to the patient survey data (Figure 3), which qualities were ranked most frequently in patients’ top five, and what caution applies to the reported percentages?
- Per Street et al (2007), what three physician behaviours are associated with better patient outcomes, and what are those outcomes?
- Describe the nested Professionalism-Ethics-Patient/Doctor model and explain what the nesting is meant to convey.
- List the factors shown shaping the patient side of the doctor-patient relationship, and explain how the doctor’s equivalent list differs.
- Per Polliak (1992), what is identified as the doctor’s most crucial attribute for entering a patient’s world, and what other factors are said to influence the doctor within the relationship?
- How do the aspects of the relationship described in Slide 5 relate to the patient and doctor factors shown in the context model?
Answers
Reveal answers
- Develop awareness of the central role of the patient-doctor relationship in clinical medicine; identify the many aspects of that relationship; reflect on the judgements made about other people; and reflect on your own aptitudes, attitudes and skills relevant to developing consultation skills over the next five years.
- Peabody held that in a large number of cases both diagnosis and treatment directly depend on the intimate personal relationship between physician and patient; a young physician’s failure to establish this relationship accounts for much of his ineffectiveness in caring for patients.
- Building trust with the patient/whanau; avoiding negative stereotypes and judgements by getting to know the patient’s/whanau’s history and context; choosing effective communication channels and language skills; cultural competence and cultural safety; legal aspects (patient rights, mental capacity, ACC etc); ethical aspects (what is right in this situation); and exploring management options including affordability.
- The most frequently top-five-ranked qualities, in order, were: is honest with you, listens carefully, treats you with respect, is competent, gives understandable information, keeps up to date, is trustworthy, involves you in decisions, maintains confidentiality, and has good personal hygiene. The percentages were estimated by eye from the chart rather than read from exact labels, so only the rank order should be treated as reliable, not the precise values.
- Physicians who are informative, show support and respect for the patient, and facilitate patient participation in care tend to have patients who are more satisfied, more committed to their treatment regimens, and who experience better health following the consultation.
- An outer “Professionalism” layer contains “Ethics”, and within Ethics sits the reciprocal Patient <-> Doctor relationship. This conveys that professionalism is the broad context within which ethics operates, and that the two-way patient-doctor relationship itself takes place within that ethical space.
- Patient factors: personality, culture and beliefs, immediate context, past experiences, past relationships, illness. The doctor’s list is the same except the last factor, which is skills and knowledge instead of illness.
- Self-knowledge is identified as the most crucial attribute. The doctor is also said to be influenced by their personal and cultural background and values, life experiences, beliefs and prejudices, educational and professional status, perception of the role of the physician and of the individual patient, and the positive or negative feelings and emotional responses the patient evokes.
- Both describe what shapes the relationship: Slide 5’s aspects (trust, avoiding stereotypes, communication, cultural competence/safety, legal and ethical aspects, management options) are the practical work of the relationship, while the context model’s patient and doctor factors (personality, culture and beliefs, context, past experience/relationships, and illness or skills/knowledge) are the underlying personal drivers that make attending to those aspects necessary.