Introduction
There is considerable healing power in good physician-patient association. The essential unit of medical practice is the moment when a person who is ill seeks advice of a doctor whom he or she trusts. These meetings are frequent and regular occurrence between doctors and their patients. The success depends not only on the doctors’ clinical knowledge and technical skills, but also on the nature of the social relationship that exists between doctor and patient.
During the last two decades, there has been a struggle over the patient's role in medical decision making often characterized as conflict between autonomy and health, values of the patient and the values of the physician. In a quest to restrain physician dominance, many have advocated an idea of greater patient control. Others question this idea because it fails to acknowledge the potentially unbalanced nature of this interaction where one party is sick and searching for security, and when judgments need the interpretation on doctor’s skill and clinical ability. This struggle shapes the expectations of physicians and patients as well as the ethical and legal standards for the physician's duties, informed consent, and medical malpractice. This scuffle forces us to ask, what should be the ideal physician-patient relationship?
The relationship between a doctor and patient is the basis of successful clinical medicine. This relationship is important for improving patient health [1,2]. Although doctor’s professional knowledge and skills for safe practice of medicine are important; the relationship with patient does affect the outcome measures.
Historically the physician-patient relationship involved patient dependence on the physicians’ professional authority [3]. The patients’ belief that they would benefit from the actions, led to patient's preferences being ignored. Such concept of beneficence allowed this authoritarian model to flourish with patients being passive recipients of the medical care. But, now there is need of the practice of mutual acceptable physician-patient relationship model in clinical set up.
We can briefly outline the four models of the physician- patient interaction [4,5].
The Paternalistic / Parental/ Priestly Model
In this model, the physician acts as the patient’s guardian articulating and implementing what is best for the patient. Physicians use their knowledge and skills to determine the patient’s medical condition, stage in disease process and identify medical test and treatments Parihar5to restore the patient’s health or ameliorate pain. Then the physician presents the patient with selected information that encourages the patient to support the intervention the physician considers best. Finally, it is believed that the patient would be grateful for decisions made by the physician even if he or she would not agree to them at the time. Hence, the physician can determine what is in the patient's best interest with limited patient participation.
The Informative/Scientific/Engineering/Consumer Model
The aim of this model is to provide the patient with all relevant information, for the patient to select the medical interventions, and for physician to execute the selected interventions. The patient is informed about disease state, the nature of possible diagnostic and therapeutic interventions, the nature and probability of risks and benefits associated with the interventions, and any uncertainties of knowledge. Here, Physicians have an important responsibility of providing truthful information, be competent in their area of expertise and consult others when they lack knowledge and skills.
The Interpretive Model
The objective is to enlighten the patient’s values and what patient actually wants, and help the patient to select the available medical interventions. In this model the physician does not dictate to the patient; it is the patient who decides which values and course of action best fit who he or she is. The physician acts as a counselor and does not judge the patient’s values instead he or she helps the patient to understand and use them in the medical situation. In addition to supplying relevant information, helping elucidate values and suggesting what medical interventions realize these values the physician has a responsibility of engaging the patient in a joint process of understanding.
The Deliberative Model
In this model, Physician provides information on patient's clinical situation and helps elucidate the types of values personified in the available options. The physician suggests why certain health-related values are more worthy and should be aspired to. Here, physician and patient take into consideration what kind of health-related values the patient could and ultimately should pursue. In the deliberative model, the physician acts as a teacher or friend, engaging the patient in dialogue on what course of action would be best. Not only does the physician indicate what the patient could do, but, knows the patient and wishes what is best and indicates that the patient must do-what decision regarding medical therapy would be worthy
Essential Elements for a Better Doctor- Patient Relationship [
6,
7]
The essential ingredients of a good doctor-patient relationship are communication, respect, confidentiality, professional honesty and trust.
Effective communication has always been important in doctor-patient relationship. Patients today are considered as health consumers and want to be active participants in decisions about their health [8]. Doctors, who educate patients, encourage patients to talk, laugh and use humours tend to have less formal complaints than those who do not do these things [9].
For a better communication the physician should sit down and attend to patient with comfort, establish eye contact, listen without interrupting, show attention with nonverbal signs such as nodding and gestures, acknowledge and legitimize feelings, and explain and reassure during examination. Good communication habits must have the following routines:
G – Greet the patients
A – Ask about their complaints
T – Tell them about various alternatives available
H – Help the patients in decision making
E – Explain use of intervention
R – Plan patients’ return visits.
Physician should avoid sceptical talks, false hopes, hopeless outlook and losing temper while communicating with patients. In a study conducted by Jenkins et al., 87% of hospitalized cancer patients interviewed desired all the information about their disease, good and bad, and 98% preferred to know whether or not their illness was cancer. The 13% who stated that in general they preferred to leave disclosure of details up to the doctor tended to be older patients (over 70 y of age) but they still wanted to know certain specific details [10].
Respect: The physician must respect the patient regardless of the patient’s attitude and background [11]. He or she must not comment on patient’s lifestyle, culture, beliefs, race, colour, gender, sexuality, age, language and social status.
Confidentiality And Privacy follow when a doctor respects the patients. The doctor is responsible for keeping the patient’s information confidential at all times unless there is a serious or imminent danger in doing so.
Professional Honesty is about the doctor knowing the limits of own competence and when to refer the patient to other doctor or paramedic. There is nothing shameful about not knowing the solution to a medical problem and it is really dangerous to fake competence or pretend to know all.
Trust is essential between doctor and patient. The best protection for doctor and patient is healthy professional boundaries. Ways of maintaining professional boundaries include:
• Knowing only relevant personal details of patient while taking a medical history
• Explaining sensitive examinations before carrying them out
• Providing privacy with screens for undressing, examination, draping or dressing along with support person
• Avoiding words, actions or jokes that are sexually demeaning or are embarrassing
• Arranging non-urgent appointment at odd hours.
In a recent study, patient-doctor relationship was discussed in response to both “belief” and “preference” questions. Their trust emerged as a key theme related to patient–doctor relationships. Some participants felt trust existed because of respect for the doctor’s position, whereas others described trust evolving over time with a particular doctor and relating to that doctor’s honesty [12].
The positive relationship between a doctor and patient are productive to both - the doctor and the patient. Benefits to doctors include higher doctor satisfaction [13] better use of time and fewer complaints from the patients [14] whereas benefits to patients include higher patient satisfaction [15] better patient adherence [16] and improved patient health. This is what most people consider to be the essential task of medicine to help patients get healthier. Thus physicians have a duty to safeguard the health of the people and minimize the ravages of disease. Their knowledge and conscience must be directed to welfare of the patients.
Implications for Teaching Doctor-Patient Relationship
The modern societal values do not support or nurture relationships. In medicine, individual achievements and technological solutions are being valued above community and wisdom. Contemporary medicine today faces a great challenge of retaining its humanity. Now-a-days we are producing more doctors but unfortunately with less values of humanity. This can be achieved by education which can counter the imbalance and model the middle way.
Firstly, teaching the science of medicine separate from art of medicine and disease as separate from the person must be resisted. The disease issues and patients’ illness must be integrated in patient-centred clinical method. Secondly, the value of relationships must be taught avoiding the perspective of breaking down caring into minute skills and behaviours. Thirdly, emphasize that each patient is surrounded by a web of caring relationships that matter to a patient's health, healing and wholeness. Fourth, engage patients as allies in teaching by encouraging them to be experts in their meetings with students (that is, to participate fully, ask questions, provide written notes about their concerns and expectations) [17].
Just like our concerns, medical students are overwhelmed, fearful and defensive. We should teach in a way we would want to be taught, thus modelling the kind of relationship we encourage our students to have with their patients [18,19]. Just as the doctor does not abandon his or her expert role when attending to the patient's voice, the teacher of medical students and trainees must not give up their role as teacher but listen more to the student's voice, enter the student's world, and open up more their inner world to model the care and the joy of being a committed prescriber.
Ethical Codes
For monitoring the concord of this relationship, ethical codes have been developed to guide the members of the profession. The Hippocratic Oath was an initial expression of such a code. In India the Medical Council of India (MCI) has also established a code of medical ethics for doctors to regulate the misconduct of the ethics in this noble profession and MCI has underlined that all the principles of ethical behaviour are applicable to all physicians including those who may not be engaged directly in clinical practice in India. Even it has been proposed by Medical Council in India that ethical issues should be included in internship curriculum studies of medical undergraduate course [20]. According to this, physicians have some responsibilities or obligations to the patients as follow:
Duties of Physicians To Patients [
20]
1. Obligations to the sick
Though a physician is not bound to treat each and every person, one should be mindful of the requirement of high character of mission and the responsibility for performance in professional duties. One should never forget that health and lives of those entrusted to his care depend on his skill and attention. A physician advising a patient to seek service of another physician is acceptable; but in case of emergency he must treat the patient. No physician could arbitrarily refuse to treat a patient, however for good reason, when an ailment which is not within the range of experience of the treating physician, he may refuse treatment and refer the patient to another physician.
2. Patience, Grace and Secrecy
Patience and gracefulness should characterize the physician. It is the responsibility of the physician to keep patient’s information confidential unless there is a serious or imminent danger in doing so. Under some circumstances, a physician may reveal it in the interest of society to protect a healthy person against a communicable disease. In such instance, the physician should act as he would wish another to act toward one of his own family in like circumstances.
3. Prognosis
The physician should neither exaggerate nor minimize the gravity of a patient’s condition. He or she should ensure that knowledge of the patient’s condition disclosed to his relatives will be for the best interest of the patient.
A physician is free to choose whom he will serve except in an emergency. Once having undertaken a case, the physician should not neglect the patient, nor should he withdraw from the case without giving adequate notice to the patient and his family. Physician could not commit an act of negligence that may deprive his patients from necessary medical care. Provisionally or fully registered medical practitioner shall not wilfully commit an act of negligence that may deprive his patient or patients from necessary medical care.
When a physician who has been engaged to attend an obstetric case is absent and another is sent for and delivery accomplished, the acting physician is entitled to his professional fees, but should secure the patient’s consent to resign on the arrival of the physician engaged.
Recently, MCI has also come out with a modified code of ethics for doctors, who have often been suspected to be ignoring the ethics of the noble profession by promoting the pharmaceutical industry’s interests. The modified code of ethics prohibits medical practitioners and their family from accepting gifts, travel facilities, hospitality and monetary grants from the healthcare industry either in their name or in the names of their family members.
Novel Concept of Patient Empowerment: The Era of Self-Service Healthcare
The traditional health systems, with patients as passive receipts of health care have proven to be unsuccessful in stemming the irresistible and exponential growth of the epidemic we now face. The very nature of chronic disease demands active patient participation: daily choices on lifestyle, exercise, Nutritution and medication play a major role. According to Robert Johnstone “doctors should get down from their pedestals, but patients must get up from their knees” which means empowerment is not about wresting power from doctors but enabling people lead more healthy and proactive lives [21].
Patient empowerment is a simple process to help people gain control. It includes people taking initiative, solving problems and making decisions. These can be applied to different setting in health and social care, and self management [21]. In the field of healthcare, empowerment has been acknowledged as an alternative to compliance in order to guide the provider–patient relationship. As discussed earlier, in the traditional approach to health-care, patients are seen as the recipients of medical decisions and prescriptions, the empowerment-oriented approach views patients as being responsible for their choices and the consequences of their choices [21].
In a systematic review conducted by Isabelle A et al., on Patient Empowerment on theory and practice: Polysemy or cacophony? Show that (i) the educational objectives of an empowerment-based approach are not disease-specific, but concern the reinforcement or development of general psychosocial skills instead; (ii) empowering methods of education are necessarily patient-centred and based on experiential learning; and (iii) the provider–patient relationship needs to be continuous and self involving on both sides [22].
Robert M et al., conducted a randomised wait listed control group trial to determine if participation in patient empowerment would improve psychosocial self efficacy towards diabetes as well as reduction in blood glucose levels. The intervention group received a six-session (one session per week) patient empowerment education program; the control group was assigned to a wait-list. At the end of six weeks, the control group completed the six-session empowerment program. Six weeks after the program, both groups provided follow-up data. It was seen that intervention group showed gains over the control group on four of the eight self-efficacy subscales and two of the five diabetes attitude subscales. Also, the intervention group showed a significant reduction in glycated haemoglobin levels [23].
Conclusion
The first priority of a committed physician is to consider the health and well-being of patient. There is considerable restorative power in the physician-patient alliance. Working together, we may have better results that can significantly improve the patient's quality of life and health status. It will help patients’ confusion, fear and doubt slowly transform into clarity, relief and assurance. With the positive role of physicians, patients will definitely be relieved of hopelessness, have higher satisfaction, better adherence and improved health. There is no doubt that this small gesture by physicians will be a precious gift to humanity.
There is still much more to understand in this relation. However one thing is certain, there is no going back to the paternalistic model of the mid 20th century and together patients and professionals will work together for the benefit of individuals and populations. So, there is need of a fundamental shift in thinking around patient empowerment. For patient empowerment to succeed, it must be firmly rooted in health systems that support and foster its wider adoption and spread. However, it has yet to play its proper role as a fundamental component to achieve mainstream status. To date there is still much more to understand in relation to a partnership approach than that has been summarized in this review.
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