Chapter 7. Doctor-patient relationship

Dr. Yeshwanth K. Amdekar, DCH, MD (Pediatrics), FIAP

Doctor is both a scientist and humanitarian, his most decisions lie in the field of patient relations David Allman

Doctor patient relationship is critical to the placebo effect Irving Kirsch

Introduction

Relationship refers the way both the parties behave with each other. Naturally, both are equally responsible for maintaining harmonious relation that is vital for successful outcome. For a doctor, professional success should be a long-term continuous process and depends on word-of-mouth& publicity while for the patient, success is one time issue related to cure of his illness. Besides, sick patient is likely to be unrealistic in his expectations and pose a challenge. Hence, primarily it is doctors responsibility to forge a harmonious relation with patients and must learn to handle situations that have potential to become a roadblock.

Foundation of ideal relationship

Contemporary medical ethics is the foundation of doctor-patient relationship. Medical ethics is a system of moral principles that apply value and judgment to medical practice. There are four pillars of medical ethics beneficence (do best to the patient), non-maleficence (do no harm), justice (impact of decision) and autonomy (respect patients rights), There are many more related important issues such as patient empowerment, confidentiality, informed consent, communication, counselling and documentation, dont run down peers, dont hide ignorance and equity (treat everyone as per the need). Ethics in medical practice is a measure of honesty, transparency, responsibility and accountability and is inseparable from medical competence. In addition, patient hearing and empathy result in quality care that builds mutual faith, respect and trust between doctor and patient. Patients dont care how much you know but definitely want to know how much you care.

Integrate art into science of medical practice

While scientific knowledge and constant updating is essential, art of medical practice is as important as science to foster ideal doctor-patient relationship. Art includes, besides ethics, basic components such as skilled planning and time management, philosophy patient hearing, honest opinion and explanation, culture organized, disciplined, courteous and respectful behavior. Perfect combination of ethics with art and science offers care always, cure if possible& in medical practice that builds mutual faith, respect and trust between doctor and patients.

Deteriorating doctor-patient relationship

Both parties are responsible though as mentioned above, doctors are expected to be proactive in fostering good relation with patients. Current scenario is far from the ideal.

Deficiencies in doctors behavior

There is an indisputable depersonalization in medical practice. Instead of making sensible decisions with basic clinical skills, there is a spurious outsourcing of common sense to modern technology. Doctors tend to treat tests rather than the disease and ignore the human being in whose body the disease resides. This has resulted in opportunity for exploitation and unethical medical practice, with profession turning into business. Rapid-fire investigations and gun-shot therapy is often based on external motivation either fear/punishment or incentives. Thus, affordable health care becomes an area of ethical conflict. Ethics, communication, counselling and documentation are often missing in pursuit of scientific outreach. Doctor-centered approach projects doctor as an expert and patient is expected to abide silently without asking questions. Conversational dominance and short time spent with the patient do not offer opportunity for discussion. Sadly, art and ethics of medical practice are not taught in medical schools and absence of role model teachers deprives medical students to learn this important aspect of medical practice. Further there is lack of control on quality of medical education and medical practice. All these deficiencies have eroded faith and image of medical profession and is the cause of deteriorating doctor-patient relationship. While every doctor would like to see his patient recover completely, his efforts must be made visible by repeated communication and counselling so that patient does not judge the doctor by the outcome. This is the only way to ensure ideal doctor-patient relationship.

Deficiencies in patients behavior

It is patients right to know about his disease and management plan. However, most patients expect cure& of the disease and relate outcome to doctors competence and efforts. They do not understand limitations of medical science and that of a doctor who cannot cure every disease even with best of competence and intentions. Earlier generation of patients had full faith in their doctors and they were satisfied with doctors best efforts irrespective of the outcome. Lack of faith in doctors of present generation of patients is the cause of poor doctor-patient relationship for which I consider doctors equally responsible. Poor outcome of a disease is often beyond control of a doctor but patients in such circumstances behave with vengeance and unacceptable violence. Outcome in other professions does not decide level of competence of a professional. A lawyer is not blamed for a defeat in a law suit and teacher is not blamed if students fail.

People understand multiple variable factors involved in final outcome. Same is true and even to a much larger extent in medical practice as outcome primarily depends on patients ability to fight and not just on doctors competence. Even when life and death is the question in medical practice, patients are not expected to behave irrationally. After all, humans are not immortal.

Consequences of deteriorating doctor-patient relationship

Unethical practices by doctors and unrealistic expectations leading to irrational behavior of patients have resulted in erosion of faith, trust and mutual respects for each other. Present generation of doctors practice defensive medicine that demands large number of tests and interventions with increase in cost of health care. It is a known fact that error of commission is more acceptable and condoned than error of omission that is punished. Doctors look at every patient as a potential litigant while patients look at the doctor as one who would cheat. This kind of behavior on the part of patients has led to increase in number of legal suits against the doctors and hence doctors justify defensive medicine. Besides doctors have to face danger to their own life and property. Hence, present generation of doctors have to spend for professional indemnity insurance against such possible events and such extra expenses are indirectly borne by patients. It has further vitiated doctor-patient relationship with disadvantage to both the parties. As such we are short of doctors in proportion to the population in India and present generation of doctors prefer their children to pursue any career other than medicine due to many adverse factors.

Can we reverse this trend?

It is possible if both the parties introspect their behavior pattern and change appropriately. Doctors must change first Time management is the key to better communication, counselling and documentation. Doctors are also required to keep updated constantly and find time for the same as medical science is dynamic and the only constant is the change. In busy practice also, doctor must find time without sacrificing quality of practice and it is possible only with group practice. This is necessary as doctor is not supposed to deny seeing a patient irrespective of time constraint and still is expected to offer best quality of service. Thus, group practice is ideal also for life of a doctor as he can find time for family and his own leisure, hobbies. Rational practice needs integration of art and science and doctors must acquire art of practice that involves ethics and empathy besides many other moral principles. Unfortunately, this is not taught in medical schools but it is left for individual doctors to follow art of practice by internal motivation that comes from within. It is the same motivation that should sensitise a doctor to keep updated in science. Once internal motivation gets started, it becomes a habit and is sustained forever. External motivation depends on fear/punishment or rewards, it is short lasting and often is a cause of stressful life. Patients also must change their behavior Patients must learn to be patient. They also have equal responsibility to facilitate ideal relationship with the doctor. They must have full faith and trust in their chosen doctor. They must understand limitations of medical science and not expect unrealistic outcomes. They must come prepared for doctors visit that enables them to describe relevant details of their complaints. They must follow doctors advice and instructions for follow-up. They must report back irrespective of improvement or otherwise. It is commonly seen that patients rarely report if they are better and it deprives the doctor of knowing his good results that boosts his confidence. Patients are expected to be transparent and honest. They should not hide any information that itself may prove to be a disadvantage to themselves such as other opinions. Lastly any bad outcome cannot justify vengeance and violence damaging doctors life, property and image. There are better methods to challenge the outcome if so desired.

Personal notes

I am very happy when patient leaves my office with satisfaction and gratitude, my day is done! I recall few instances when patients were argumentative and I have learnt not to counteract even if patients are wrong. I remember an incidence when a child with fever was brought to me for second opinion and his mother asked me whether fever could be due to multiple myeloma. I was surprised to hear such a question. She informed me that she herself had similar fever that was finally diagnosed as multiple myeloma and her doctor had missed it completely for which she had decided to confront him and take him to the court. I knew the concerned doctor as most honest and competent physician and felt bad for him but avoided any further conversation. Few months later, when I met this mother, she herself narrated what happened when she went to fight with the doctor who had missed her diagnosis. When this doctor was shown final diagnosis made by another doctor, he banged his fists on the table and agreed that he had missed the diagnosis and it was his fault. This honest behavior of the doctor made this lady to decide against going to the court. Honesty is the best option and not the defensive argument to justify wrong action. I know of a very competent doctor when asked by his patient whether he was sure of his diagnosis, was upset and angrily said do you know whom you are questioning, I talk only when, I am sure.& This is ego and rudeness. Patient swore not to see him again in spite of his competence and commitment. We must mind our tongue!

Take home message

We must accept the fact that there is definite deterioration of doctor-patient relationship. Cordial relation plays such an important part in management of diseases. It is bipartite responsibility though doctors should be proactive in forging such a relationship. Time is the key factor for doctors and they must find ways to manage time for which group practice is an ideal solution. It also improves doctors private life. Patients must be equally honest and transparent and must have full faith and trust in their chosen doctor. Unrealistic expectations and irrational behavior is not acceptable at any cost as there are better methods available for redressing their grievances.

Chapter 7. Doctor-patient relationship