- The Benefits of a Trusting Physician-Patient Relationship
- The Doctor–Patient Relationship: Challenges, Opportunities, and Strategies
- ‘Only connect’: the centrality of doctor–patient relationships in primary care
- The centrality of relationship-based primary care
- Empowerment and personal relationships
- Does a Real Physician-Patient Relationship Exist Anymore?
- Patient Interactions Will Vary
- Trust: The keystone of the physician-patient relationship | The Bulletin
- Trust: The keystone of the physician-patient relationship
- Communication: A means of developing trust
- Keeping the arch stable for a rewarding career
The Benefits of a Trusting Physician-Patient Relationship
The Oxford English dictionary1 defines trust as firm belief experience, qualities such as honesty and veracity, and actions such as justice and strength of a person or thing.
Two-thousand three hundred years ago the Hippocratic oath originally outlined appropriate trust-building behavior for physicians.
The sustained use of the oath reflects how profoundly important physician behavior is for establishing trust in relationships with patients.
The study by Thom2 in this issue of JFP is grounded in a previous publication input from patient focus groups3 and identifies the physician behaviors that are most important to the patient for building a trusting relationship.
As we review this work and others it is important to remember why trust between physicians and their patients contributes to an effective and affordable health care system. Thom has confirmed that the most important predictors of trust are similar to the predictors of patient satisfaction.
Stewart4 found that the more patient-centered the interview and the more the physician and patient feel equal partners, the better the outcomes for the patient’s health problem.
Starfield5 found that 40% of all new problems presented to a family physician are nonspecific and never evolve into a defined International Classification of Diseases-9th revision or Diagnostic and Statistical Manual of Mental Disorders, 4th edition diagnosis.
Undifferentiated problems can often be dealt with by competently reassuring and educating the patient and inviting return if the problem does not improve in a few days. The skill of accurately identifying conditions best managed by “watchful waiting” has been well developed by family physicians, and this policy is ly to work best in a trusting relationship.
Trust enables the patient to accept the physician’s recommendation for self-monitoring and makes it less ly that the physician practices defensive medicine.
The potential for increased costs to the health system resulting from a breakdown of patient trust is substantial. Patients who do not accept a wait-and-see strategy from a physician whom they do not trust are ly to require potentially costly consultations.
The usual outcome of investigating undifferentiated problems is an unsatisfactory nondiagnosis that heightens patient anxiety about the presence of serious disease. The risk of increased morbidity and mortality secondary to unnecessary testing cannot be ignored.
Current research supports patient-centered decision making to enhance adherence to treatment regimens and improve outcomes.
Even though patients did not value shared decision making very strongly in the study by Thom, Leopolde and colleagues7 emphasize the need to establish a partnership with patients as a means of increasing trust.
The physician brings to the partnership knowledge and skills about health care that may be of benefit to the patient, while the patient brings values and beliefs from the context of his or her environment.
Both partners search for common ground and negotiate the best course for the patient. Although the potential for increased system costs and negative outcomes from lack of trust is substantial, there is a paucity of research regarding managing undifferentiated problems.
Thanks to the research of Thom and others, we know the behaviors that patients most strongly associate with enhanced trust. These include comforting and caring, demonstrating competency, encouraging and asking questions, and explaining.
More surprising is that patients find less value in gentleness during the examination, discussing options and asking opinions, looking in the eye, and being treated as an equal.
This information advances our understanding of the patient’s perspective on trust while also shattering some myths.
Focus groups in an earlier study by Thom and Campbell3 identified other factors influencing trust, including the age and sex of the patient, the training and professional appearance of the physician, positive recommendation by other patients and physicians, and the operation of the physician’s office.
Staff courtesy, management of messages and laboratory results, and on-call arrangements that ensure accessibility are important in cementing trust in a relationship.
2 System intrusions on the physician-patient relationship, such as mandating screening tests for all, disallowing the ordering of specific tests (usually expensive), or blocking prescribing of newer drugs, threaten trust in the physician-patient relationship.
Organizations or governments giving physicians financial incentives to provide screening or other procedures tempt physicians to place their own interests before those of the patient. This point is illustrated in managed care organizations. Kao and coworkers8 found that the way physicians are paid influences the level of trust in the relationship.
Physicians salaried by a health maintenance organization (HMO) were found to garner a lower level of trust than with fee-for-service private physicians. In addition to intruding in the decision-making process, long-term continuity of care is difficult in instances when the HMO provider is changed frequently and not allowed to build trust with patients.
The Doctor–Patient Relationship: Challenges, Opportunities, and Strategies
1. Lipkin M Jr, Putnam SM, Lazare A, editors. The Medical Interview: Clinical Care, Education, and Research. New York, NY: Springer-Verlag; 1995. [Google Scholar]
2. Tessler R, Mechanic D. Factors affecting the choice between prepaid group practice and alternative insurance programs. Milbank Mem Fund Q Health Soc. 1975;53(2):149–72. [PubMed] [Google Scholar]
3. Garfinkel SA, Schlenger WE, McLeroy KR, et al. Choice of payment plan in the Medicare capitation demonstration. Med Care. 1986;24(7):628–40. [PubMed] [Google Scholar]
4. Grazier KL, Richardson WC, Martin DP, Diehr P. Factors affecting choice of health care plans. Health Serv Res. 1986;20(6 pt 1):659–82. [PMC free article] [PubMed] [Google Scholar]
5. Sofaer S, Hurwicz ML. When medical group and HMO part company: disenrollment decisions in Medicare HMOs. Med Care. 1993;31(9):808–21. [PubMed] [Google Scholar]
6. Emanuel EJ, Dubler NN. Preserving the physician-patient relationship in the era of managed care. JAMA. 1995;273(4):323–9. [PubMed] [Google Scholar]
7. Mechanic D, Schlesinger M. The impact of managed care on patients' trust in medical care and their physicians. JAMA. 1996;275(21):1693–7. [PubMed] [Google Scholar]
8. Mechanic D. Changing medical organization and the erosion of trust. Milbank Q. 1996;74(2):171–89. [PubMed] [Google Scholar]
9. Rodwin M, editor. Medicine Money and Morals: Physician's Conflict of Interest. New York, NY: Oxford University Press; 1993. [Google Scholar]
10. Angell M. Cost containment and the physician. JAMA. 1985;254:1203–7. [PubMed] [Google Scholar]
11. Gordon GH, Rost K. In: The Medical Interview: Clinical Care, Education, and Research. Lipkin M Jr., Putnam SM, Lazare A, editors. New York, NY: Springer-Verlag; 1995. pp. 248–53. Evaluating a faculty development course on medical interviewing. [Google Scholar]
12. Levinson W, Roter D. The effects of two continuing medical education programs on communication skills of practicing primary care physicians. J Gen Intern Med. 1993;8:318–24. [PubMed] [Google Scholar]
13. Lipkin M., Jr. In: Behavioral Medicine in Primary Care: A Practical Guide. Feldman M, Phil M, Christensen J, editors. Stamford, Conn: Appleton-Lange; 1997. pp. 1–7. The medical interview. [Google Scholar]
14. Lazare A, Putnam SM, Lipkin M., Jr. In: The Medical Interview: Clinical Care, Education, and Research. Lipkin M Jr., Putnam SM, Lazare A, editors. New York, NY: Springer-Verlag; 1995. pp. 3–19. Three functions of the medical interview. [Google Scholar]
15. Dye NE, DiMatteo MR. In: The Medical Interview: Clinical Care, Education, and Research. Lipkin M Jr., Putnam SM, Lazare A, editors. New York, NY: Springer-Verlag; 1995. pp. 134–44. Enhancing cooperation with the medical regimen. [Google Scholar]
16. Kaplan S. Patient activation. Washington, DC: 1997. Presented at Royal College of Medicine symposium on Doctor Patient Communication. [Google Scholar]
17. Stewart MA, Brown J, Levenstein J, McCracken E, McWhinney IR. The patient-centered clinical method: changes in residents' performance over two months of training. Fam Pract. 1986;3:164–7. [PubMed] [Google Scholar]
18. Carkhuff R. Art of Helping. Amherst, Mass: Human Resources Development Press; 1972. [Google Scholar]
19. Peabody FW. The care of the patient. JAMA. 1927;88:877–82. [Google Scholar]
20. Rogers C. A Way of Being. Boston, Mass: Houghton Mifflin; 1980. [Google Scholar]
21. Kaplan SH, Greenfield S, Ware JE. Assessing the effects of physician-patient interactions on the outcome of chronic disease. Med Care. 1989;27(suppl):S110–27. [PubMed] [Google Scholar]
22. Orth JE, Stiles WB, Scherwitz L, Hennrikus D, Vallbona C. Patient exposition and provider explanation in routine interviews and hypertensive patients' blood pressure control. Health Psychol. 1987;6:29–42. [PubMed] [Google Scholar]
23. Starfield B, Wray C, Hess K, Gross R, Birk PS, D'Lugoff BC. The influence of patient-practitioner agreement on the outcome of care. Am J Public Health. 1981;71:127–31. [PMC free article] [PubMed] [Google Scholar]
24. Tuckett D, Boulton M, Olson C, Williams A. Meetings Between Experts: An Approach to Sharing Ideas in Medical Consultations. New York, NY: Tavistock Publications; 1985. [Google Scholar]
25. Egbert LD, Battit GE, Welch CE, Bartlett MK. Reduction of postoperative pain by encouragement and instruction of patients. N Engl J Med. 1964;270:825–7. [PubMed] [Google Scholar]
26. Hall JA, Roter DL, Katz NR. Meta-analysis of correlates of provider behavior in medical encounters. Med Care. 1988;26:657–75. [PubMed] [Google Scholar]
27. Roter DL. Patient participation in the patient-provider interaction: the effects of patient question asking on the quality of interaction, satisfaction, and compliance. Health Educ Monogr. 1977;5:281–315. [PubMed] [Google Scholar]
28. Putnam SM, Lipkin M., Jr. In: The Medical Interview: Clinical Care, Education, and Research. Lipkin M Jr., Putnam SM, Lazare A, editors. New York, NY: Springer-Verlag; 1995. pp. 530–7. The patient-centered interview: research support. [Google Scholar]
29. Gerteis M, Roberts MJ. In: Through the Patient's Eyes. Gerteis M, Edgman-Levitan S, Daley J, Delbanco TL, editors. San Francisco, Calif: Jossey-Bass Publishers; 1993. Culture, leadership and service in the patient-centered hospital. [Google Scholar]
30. Brody H. The Healer's Power. New Haven, Conn: Yale University Press; 1992. [Google Scholar]
31. Arnold R, Forrow L, Barker LR. In: The Medical Interview: Clinical Care, Education, and Research. Lipkin M Jr., Putnam SM, Lazare A, editors. New York, NY: Springer-Verlag; 1995. pp. 345–67. Medical ethics and doctor/patient communication. [Google Scholar]
32. Ubel P, Goold SD. Recognizing bedside rationing: clear cases and tough calls. Ann Intern Med. 1997;126(1):74–80. [PubMed] [Google Scholar]
33. Eddy DM. Cost-effectiveness analysis: will it be accepted? JAMA. 1992;268:132–6. [PubMed] [Google Scholar]
34. Jecker NS, Pearlman RA. An ethical framework for rationing healthcare. J Med Philos. 1992;17:79–96. [PubMed] [Google Scholar]
35. Kleinman A, Eisenberg L, Good B. Culture, illness, and care: clinical lessons from anthropologic and cross-cultural research. Ann Intern Med. 1978;88:251–8. [PubMed] [Google Scholar]
36. Halpern J. Can the development of practice guidelines safeguard patient values. J Law Med Ethics. 1995;23(1):75–81. [PubMed] [Google Scholar]
37. Deming WE. the Crisis. Cambridge, Mass: Massachusetts Institute of Technology, Center for Advanced Engineering Study; 1986. [Google Scholar]
38. Roland MO, Bartholomew J, Courtenay MJF, Morris RW, Morrell DC. The “five minute” consultation: effective time constraint on verbal communication. BMJ. 1986;292:874–6. [PMC free article] [PubMed] [Google Scholar]
39. Tamblyn R, Berkson L, Dauphinee W, et al. Unnecessary prescribing of NSAIDs and the management of NSAID-related gastropathy in medical practice. Ann Intern Med. 1997;127:429–38. [PubMed] [Google Scholar]
40. Hjortdahl P, Laerum E. Continuity of care in general practice: effect on patient satisfaction. BMJ. 1992;304(6837):1287–90. [PMC free article] [PubMed] [Google Scholar]
41. Goold SD. Allocating health care resources: cost utility analysis, informed democratic decision making, or the veil of ignorance? J Health Polit Policy Law. 1996;21(1):69–98. [PubMed] [Google Scholar]
42. Sofaer S, Hurwicz ML. When medical group and HMO part company: disenrollment decisions in Medicare HMOs. Med Care. 1993;31(9):808–21. [PubMed] [Google Scholar]
43. Lipkin M. The medical interview as core clinical skill: the problem and the opportunity. J Gen Intern Med. 1987;2(5):363–5. [PubMed] [Google Scholar]
44. Gerteis M, Edgman-Levitan S, Daley J, Delbanco TL, editors. Through the Patient's Eyes. San Francisco, Calif: Jossey-Bass Publishers; 1993. ch. 10. [Google Scholar]
45. Daniels N. Why saying no to patients in the United States is so hard: cost containment, justice, and provider autonomy. N Engl J Med. 1986;314(21):1380–3. [PubMed] [Google Scholar]
46. Weber LJ. The business of ethics: hospitals need to focus on managerial ethics as much as clinical ethics. Health Prog. 1990;71(1):76–8. 102. [PubMed] [Google Scholar]
47. Goold SD. Money and trust: relationships between patients, physicians and health plans. J Health Polit Policy Law. 1998;23:687–95. [PubMed] [Google Scholar]
48. Ubel PA, Goold SD. Does bedside rationing violate patient's best interests? An exploration of the moral relevance of “moral hazard.” Am J Med. In press. [PubMed]
49. Scott RA, Aiker LH, Mechanic D, Moravcsik J. Organizational aspects of caring. Milbank Q. 1995;73(1):77–95. [PubMed] [Google Scholar]
50. Mao Tse Tung. Quotations from Chairman Mao. San Francisco, CA: China Books; 1975. [Google Scholar]
51. Clark W, Lipkin M, Jr, Graman H, Shorey J. Improving physicians' relationships with patients. J Gen Intern Med. 1999;14(suppl 1):S45–50. [PMC free article] [PubMed] [Google Scholar]
‘Only connect’: the centrality of doctor–patient relationships in primary care
Centrality, doctor–patient relationship, primary care
Celia Roberts. ‘Only connect’: the centrality of doctor–patient relationships in primary care. Family Practice 2004; 21: 232–233.
EM Forster's call in A Passage to India to ‘only connect’ is a shorthand for the hundreds of ways in which doctor–patient relationships have been discussed in the literature.
As Chew-Graham states, in the parallel editorial, this relationship, and the patient-centred ideology which underpins it, is seen as intrinsically therapeutic.
The evidence base for such an assumption is well established, most notably in the literature on quality and continuity of care.
The centrality of relationship-based primary care
There is a strong association between personal continuity, enablement and patient satisfaction.1 Since personal continuity implies both empathy and personal responsibility,2,3 the studies overall show a strong correlation between quality relationships and patient satisfaction.
Reviews of patient satisfaction studies show that along with doctors' medical skills, qualities such as listening4 and interpersonal skills5 are rated as highly.
Empathy,6 ease of communication and friendship,7 trust8 and commitment are all associated with personal continuity and highly valued by patients.
These characteristics are particularly important for patients with chronic illnesses and complex problems, and for the elderly. The young and fit seem less concerned with personal relationships.9 Patients with ongoing problems benefit from ongoing good relations with the GP.
As well as the evidence base from patient satisfaction studies, the sociological and linguistic studies of interaction show a strong relationship between involvement in talk and understanding.
‘Troubles telling’10 and patient narratives11,12 show the importance of doctor–patient interactions, which give room for patients to speak throughout consultations and over several consultations. ‘Giving room to speak’ encourages patients to tell their stories.
So history taking becomes an interpretive process in which the patient's particular take on their illness is explored.13 The relationship which develops through patient narrative is not only therapeutic in a general sense, it also provides the conditions for understanding and the avoidance of misunderstandings.14
Empowerment and personal relationships
The post-Balint move to more interpretive and empathic consultations is not just a shift to more psychosocial models but is also a shift in interactional models, from hierarchical to more flattened structures and role relationships between GP and patient.
More interactional equality is assumed in the current discourses of ‘concordance’ and ‘shared decision making’. Knowledge is shared and outcomes negotiated; resistances are acknowledged. However, more negotiation in the consultation does not fundamentally undermine the power asymmetries of the GP–patient relationship.
The professional expertise of doctors pre-determines this imbalance and it is routinely consented to by patients.15
GPs' feelings of disempowerment, according to Chew-Graham, stem from a combination of patients' intractable problems and the fact that creating and maintaining good personal relations undermines their authority to deal with these problems. The argument is not that doctors have less professional expertise but that they are inhibited from exerting their authority to gain compliance from patients.
However, the evidence on continuity of care and patient satisfaction referred to above suggests that empowerment for GPs is the result of more concentration on doctor–patient relationships rather than less.
The discourses of ‘burnt out doctors’ and ‘heart sink patients’ are understandable defence mechanisms for GPs coping with the levels of chronic illness and complex social problems typical of general practice today.
However, rather than turning away from more negotiated and democratic consulting styles, their value as tools of persuasion and joint agreement should be explored further.
A sense of powerlessness can lead to feelings of nostalgia for the ‘good old days’ when a GP's natural authority and technical skills led to rational decisions for compliant patients.
However, both this technocratic and rational model of medicine and the ideology of authoritarian role relations seem inadequate in the face of increasingly complex medical and social problems, on the one hand, and more general social changes and uncertainties, on the other.
Simple distinctions between health and illness, and sickness and recovery, and the clinical goals that these imply, are not always sustainable. Herzlich describes how some chronically ill patients treat ‘illness as occupation’. They work on making adjustments to their lives, rather than assuming that they will certainly get better.
They see themselves as creating a new form of life in which they do not define themselves as fundamentally different from healthy people.16 Patients recognize that the illness narrative does not always end in straightforward recovery.
Similarly, for a GP, success with a patient may reside in the long-term therapeutic relationship with the patient rather than the happy ending of a complete recovery. The act of supporting the patient in itself is a successful outcome.
Maintenance of the relationship and the therapeutic or palliative effect produced can give satisfaction and boost morale for both doctor and patient.17 Such relationships may help the patient to avoid taking strong drugs or help them to manage without being institutionalized.
18 The trust, friendship and sense of sustained partnership which personal continuity brings is more ly to improve the taking of medication than an approach which pays less attention to personal relationships.
19 Indeed, it is counter-intuitive to assume that GPs are more ly to be able to persuade patients to take medication, give up smoking or alter their diet if there is less concern about creating trust, commitment and a sense of partnership.
The sense of frustration and exhaustion that GPs report when working with the often irresolvable problems of the chronically sick stem more from a strict adherence to biomedical goals and an undervaluing of the contribution they can make to the patients' management of their illness.
The latter depends crucially on the quality of the personal doctor–patient relationship and the trust, commitment and friendship which, the studies show, are more ly than not to develop. Gray et al.
argue that when GPs are not able to develop such relationships they should consider moving to other branches of medicine: “Some doctors are intrinsically unsuited to relationship-based primary care and might be happier moving to a speciality such as accident and emergency medicine”.
20 They argue that doctors who have as a goal the understanding of their patients as people and can build up mutual trust with them are much more ly to have a sense of job satisfaction and to feel valued.
The expertise and practical wisdom which are being grown in the humanistic undergraduate programmes, in both well-established and new medical schools, share this goal. Tomorrow's doctors are ly to be more equipped to understand, support and work with the chronically ill towards negotiated and achievable outcomes, and to derive a sense of worth and satisfaction from this, but only because the personal doctor–patient relationship is at the centre of their working practices.
Guthrie B, Wyke S. Does continuity in general practice matter? ; : –736.
Howie J, Heaney D, Maxwell M, Walker J, Freeman G, Rai H. Quality at general practice consultations: cross sectional survey. ; : –743.
Freeman G, Hjortdahl P. What future for continuity of care in general practice? ; : –1873.
Lewis R. Patient views on quality care in general practice: literature review. ; : –670.
Williams S, Calnan M. Key determinants of consumer satisfaction with general practice. ; : –348.
Mercer S, Watt G, Reilly D. Empathy is important for enablement. ; : .
Gabel L, Lucas J, Westbury R. Why do patients continue to see the same physician? ; : –1347.
Anderson L, Dedrick R. Development of the Trust in Physician Scale: a measure to assess interpersonal trust in patient–physician relationship. ; : –1100.
Fairley R. Patients who usually consult the trainee in general practice. ; : –35.
Jefferson G, Lee J. The rejection of advice: managing the problematic convergence of a ‘troubles telling’ and a ‘service encounter’. ; : –422.
Greenhalgh T, Hurwitz B. Why study narrative? ; : –50.
Elwyn G, Gwyn R. Stories we hear and stories we tell: analysing talk in clinical practice. ; : –188.
Gwyn R. Communicating Health and Illness. London: Sage; .
Britten N, Stevenson F, Barry C, Barber N, Bradley C. Misunderstandings in prescribing decisions in general practice: qualitative study. ; : –488.
Silverman D. Communication and Medical Practice. London: Sage; .
Herzlich C. Health and Illness. London: Academic Press, .
Blankfield R, Kelly R, Allegmagne S, King C. Continuity of care in a family practice residency programme: impact on physician satisfaction. ; : –73.
Kearley K, Freeman G, Heath A. An exploration of the value of the personal doctor–patient relationship in general practice. ; : –718.
Ettlinger P, Freeman G. General practice compliance study: is it worth being a personal doctor? ; : –1194.
Gray D, Evans P, Sweeney K et al. Towards a theory of continuity of care. ; : –166.
Does a Real Physician-Patient Relationship Exist Anymore?
William Gilkison, MD, family physician from Indianapolis, still has feelings of rejection after a young family he treated decided to switch to another physician – with no warning signs.
It was decades ago, when Gilkison had just begun his career. Many of his early patients had been referred to him by another local doctor who had retired, and life was good.
“I felt blessed that so many new families were coming my way,” he said. Two parents and their four children under the age of 16 — seemed to Gilkison a perfect fit. He imagined that he'd care for all of the members of this family for years.
But after a few visits, with no warning signs, the matriarch of the family sent the practice a written notice requesting that their records be sent to another doctor.
“Years later, I still have feelings about that rejection,” he said, adding that so early in his practice, he generally assumed that all of his patients would him. “To some degree, I guess the loss is similar to losing a patient [who dies] in that you don't ever see them again.”
Gilkison eventually learned that patients choose and leave doctors for a variety of reasons.
For sure, doctor/patient relationships are often not what they used to be. Whereas patients used to stay loyal to their physician for a long time, today it's common that if their employer's insurance changes, the patient switches to a new doctor.
And because visits are often shorter than they were in the past, doctors and patients have less conversation time to build a relationship.
The situation became even worse when doctors began spending visit time typing into an electronic health record (EHR) and eye contact lessened.
And yet, in the Medscape Physician Compensation Report 2019, physicians revealed that gratitude from and relationships with patients topped the list of what made their jobs rewarding. So it's not surprising for a physician to feel the sting of a patient's leaving so acutely.
Patient Interactions Will Vary
“Forming relationships with people, having someone come in and learning about their work or where they have traveled, getting to know them a bit on the nonmedical side has become in a lot of ways more important and more fun,” said David Neiblum, MD, a gastroenterologist in West Chester, Pennsylvania. For some physicians, these priorities emerge as they become more masterful at the clinical side of caregiving, said Neiblum. “A lot of doctors will say that the longer you do something, the more routine it gets,” he said.
What makes a fulfilling physician-patient relationship varies among physicians. For Neiblum, his role is to tune in to the patient in terms of what he or she is looking for in a doctor. “You want to gauge their personality, mostly to get them to trust you, so that they will share things and be receptive to your recommendations.”
For example, while a hard-charging CEO might expect direct answers to a lot of tough questions, a patient with a history of drug abuse could require more trauma-informed care.
In other cases, patients come in afraid their symptoms indicate cancer. “My job is first to make sure they don't have cancer, but second to calm them down and reassure them that chances are higher that they don't have something terrible,” he said. “Building trust is absolutely essential.”
In a recent survey about what makes a strong physician-patient relationship, the top answer was, “we share decision-making and collaborate on treatment plans” (20%), followed closely by “visits are warm and friendly with good communication” (19%).
The notion of shared decision making is relatively new in medicine, noted Adam Cifu, MD, professor of medicine and associate dean of medical school academics at the University of Chicago. “I think physicians [today] expect a more collaborative relationship with patients,” he said. “Whether they it or not, that's the reality. For the most part, it's very positive.”
Collaboration in medicine has become so important that the Society for Participatory Medicine (SPM) released a Participatory Medicine Manifesto, signed by physician attendees at its 2019 annual conference, held in Boston.
In doing so, these physicians pledged their commitment to share and listen; respect one another; share information responsibly; promote curiosity; and be a team builder.
As a result of this evolution, patients come in armed with more information and often clearer expectations, Cifu said. “It's sometimes a challenge, though, because that's the cultural shift in how we've educated the current generation of physicians.”
The tricky part comes in when a patient prefers for physicians to give them recommendations to follow, Cifu said. In other situations, it might be clinically necessary for a physician to overrule a patient.
“It's funny that these days, I find that it takes some teaching to get trainees to say, 'This is the situation, and this is the right treatment,' because they've been schooled so much in patient autonomy that it's often harder to shift when necessary.”
To make a physician/patient relationship satisfying, both parties need to feel involved and respected.
Consistent with survey results, many physicians valued patient-physician communication as a chief factor in building a relationship.
“From a patient's perspective, the most important things are knowing that you're going to be heard and that a real effort is going to be made to get the appropriate care for you that's personalized to your values,” Cifu said.
Importantly, physicians also want to be heard. “Physicians often get frustrated with their relationships because people come in with a preformed idea about what's going on and what should happen; and when they don't get that, they get aggravated,” Cifu said. “Then you hear doctors say, 'Why do they come for my advice if they don't want to hear it?' “
Physicians often get frustrated with their relationships because people come in with a preformed idea about what's going on and what should happen; and when they don't get that, they get aggravated. Dr Adam Cifu
To head off this problem, some physicians ask new patients to tell them what they expect from them as a doctor. And some physicians will lay out their expectations for the patient as well. “It's an interesting way to begin a relationship, but I think it's not a bad one,” Cifu said.
Barriers to connecting with patients are pervasive. Some problems are endemic to the medical system itself. “Insurers sometimes make it difficult to really treat someone,” said Neiblum. For example, payers may put up roadblocks to ordering certain tests, or the best medication to treat a patient's condition may not be covered by his or her insurance.
“These problems with modern medicine can get in the way of the relationship,” Neiblum added. But there are ways physicians can repair fractured patient relationships, including a letter of apology.
During a panel discussion at this year's SPM conference about missed connections in healthcare, audience member Ashley Clayton, MA, director of research and evaluation at the Center for Wellbeing of Women and Mothers in the Department of Psychiatry at the Yale School of Medicine, shared part of her struggle to access lifesaving treatment for depression. This was chronicled in a recent essay published in Health Affairs.
During the session, Clayton explained that although her difficulties were, as Neiblum suggests, connected to systemic problems, receiving a written apology from her physician made all of the difference in their relationship going forward. “It's stronger than it's ever been,” she said.
Although physicians indicate that collaborative relationships with patients are rewarding, they're not always thrilled when patients attempt to diagnose themselves through Internet research or insist on a treatment recommended by a celebrity doctor.
“It's ironic,” said Cifu, “because on the one hand, all you're hearing these days is about personalized medicine.” This broadly means tailoring to the individual. “And the exact opposite of that is the single physician speaking to millions or people searching a generic complaint on the Internet,” he said.
Nonetheless, the Web is a valuable tool that can help balance the knowledge level between physician and patient, Cifu noted. “It's not one person knowing everything and the other person knowing nothing. It helps the patient have a bit more educated conversation about it all.”
If trust and clear communication have already been established in the relationship, such conversations can be productive, even if they don't result in fulfilling the patient's requests.
“Ideally, the patient still needs to trust that what the doctor is saying is robust evidence,” Cifu said.
And if a recommendation is based more on a hunch, he advises telling a patient that the treatment may or may not work, along with the reasons for the suggestion.
This type of dialogue can keep both sides from getting defensive and will hopefully strengthen the relationship in the long term.
Medscape's poll also showed that almost all of the physicians surveyed receive some form of appreciation from their patients often or sometimes.
“I'm not surprised when people express appreciation, because they realize that the clinician is working, spending time, and thinking about how to care for them,” he said. “It's clear that when physicians do a better job with patients they , who they're invested in, that it's in everybody's best interest to have a relationship that.”
It's clear that when physicians do a better job with patients they , who they're invested in, that it's in everybody's best interest to have a relationship that. Dr Adam Cifu
Cifu said that he is sometimes caught off guard when patients express no appreciation to the caregiver and are also sometimes difficult. “They treat you as though they never plan to see you again.”
Physicians don't expect elaborate shows of gratitude. “I've gotten cards and gifts and positive reviews over the years, but it's not expected. It's a little bit of icing,” Neiblum said. “But if someone just says 'thank you' with a smile, I'm happy.”
Physicians have various ways of reciprocating their feelings to patients, which include verbal confirmation, a handshake, or a hug. But it's also not uncommon for physicians to focus on the computer screen more than the patient or frequently interrupt while the patient is speaking, Neiblum said.
“It's a big problem,” he said. “So I try to force myself to ask patients why they're here and wait a few minutes before I say anything. Some personal contact, a hand on the shoulder, is very good. I'm very cognizant to talk with the patient and not get sucked into the computer.”
Cifu doesn't agree that the EHR is responsible for the demise of the physician-patient relationship. He noted that many patients would be frustrated if a physician could not access their entire record right in the room.
Although physician/patient relationships may face more challenges now than in the past, they are still at the heart of the reason why physicians choose their profession. And many patients consider those relationships equally as important.
Debra A. Shute is a freelance healthcare journalist based in the Greater Boston area.
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Cite this: Does a Real Physician-Patient Relationship Exist Anymore? – Medscape – Dec 10, 2019.
Trust: The keystone of the physician-patient relationship | The Bulletin
Editor’s note: Dr. Pellegrini presented the John J. Conley Ethics and Philosophy Lecture at Clinical Congress 2016 in Washington, DC. Dr. Pellegrini was invited to submit the following column, which highlights the key points he made in that lecture. The address was published online in October 2016 in the Journal of the American College of Surgeons.
John J. Conley, MD, FACS, an otolaryngologist, felt that in order to provide the best care to patients, surgeons should be trained in skills that extend beyond the technical aspects of surgery. With this objective in mind, he established the Ethics and Philosophy Lecture at the Clinical Congress of the American College of Surgeons, which now bears his name.
During my years as a surgeon, I realized that my ability to heal and provide comfort to my patients was substantially enhanced when I developed a bond of trust and a strong relationship with them. As I started working on ways to achieve that goal, I recognized the impact that those enhanced relationships had on me as a person and on my colleagues.
Trust: The keystone of the physician-patient relationship
I envision the patient-physician relationship, and by extension the relationship that surgeons develop with other members of the team and with themselves, as an arch; the surgeon represents one pillar, and the other party represents the other pillar. Trust is that stone at the top of the arch—the so-called keystone on which the stability and the integrity of the arch is dependent. Indeed, I am convinced that trust is to a relationship a keystone is to an arch—essential for its integrity.
Trust is defined as “assured reliance on the character, ability, strength, or truth of someone or something.”1 Trust does not usually result from a single interaction, but instead it is built over time, with repeated interactions through which expectations about a person’s trustworthiness can be tested.
In medicine, our patients expect that we, as physicians, will behave in a certain way. In this relationship, the patient is the trusting party and must have confidence that we will act for their benefit.2 This intrinsic trust in the physician is expressed in the discretionary latitude that patients give their physicians to do what is necessary to, hopefully, benefit their well-being.
In the world of medicine, trust results from a number of interactions and the patient’s perception of the physician’s technical competency, interpersonal attributes, and values, as well as the patient’s impression of how the system works, including the reputation of the institution.
In addition, medicine emphasizes the affective nature of trust, identifying patient trust as reliance on the physician and the physician’s intent.3 In surgery, our power to heal extends far beyond our technical prowess and is directly influenced by the relationship we establish with our patients.
Indeed, studies show that patient trust in a physician increases the lihood of adherence to treatment recommendations and satisfaction with the physician’s care.
It is important to consider our patients’ vulnerability in the relationship. For physicians to fulfill their commitment to trust, they must protect, rather than exploit, this vulnerability.
To do so, the physician must place the medical good in the context of the patient’s assessment of what is good.
More specifically, the physician must recognize that although he or she has expert knowledge of the medical facts, the patient is the expert when it comes to determining what is best for him or her given his or her values, beliefs, and aspirations.
2 Hence, the physician is obligated to present clinical data as free as possible of personal or professional bias and to assist patients in understanding the rationale, effectiveness, benefits, and potential risks of a treatment plan without manipulation or coercion.
Just as the patient must be able to trust the physician, the physician needs to have trust in the patient. Mutual trust is an important aspect of the patient-physician relationship with potential benefits for each party.
Trust improves cooperation and reduces the need for monitoring.4 A physician’s trust in the patient enhances the relationship and contributes significantly to the physician’s sense of well-being and professional satisfaction.
Another form of trust plays an important role in medicine—the “social trust,” which has to do with the patient’s trust in the institutions where they receive care. Every individual enters a consultation with a certain element of trust in the institution or site of practice.
The patient’s interaction with the system as well as the physician will reinforce or undermine both social and interpersonal trust. For example, when physicians make positive comments about staff and other members of the medical profession, social and interpersonal trust are enhanced.
On the other hand, if a patient perceives a lack of continuity in the system, it ly will undermine social and interpersonal trust.
It is my advice to you that in your interactions with patients, always keep in mind the power that you have with your words and behaviors to enhance both social and interpersonal trust.
Trust is the keystone of a patient-physician relationship. It is an indispensable virtue of a good physician. Without this virtue, the relationship disintegrates, just as happens to an arch when the keystone is removed. With it, we enhance our ability to heal the body and the soul of the patient, the physician, and the patient care team.
Communication: A means of developing trust
If trust is a defining element in any interpersonal relationship, then communication is the most effective and efficient means of engendering trust.
I am of course talking about communication in a much broader sense than the traditional concept. Most of the communication I refer to is, in fact, nonverbal.
To create rich relationships with our patients, team members, and, indeed, ourselves, we must use all communication tools available to us.
Human beings use a wealth of methods to communicate with one another, and the process is remarkably complex. Communication is a science and an art that requires substantial skill. It is not just about what we say, but rather far more about how we say it, and then how it is interpreted.
It is how we behave, the way we listen, the manner in which we deliver on what we say, how we treat others, and how others perceive our treatment. It is the way we perceive the patient’s feelings beyond their words and the way we ask questions that perception. It is the way we relate to the patient’s family, clinic staff, and the organization in which we work.
All the ways we communicate have a tremendous impact on developing, building, and reinforcing trust.
And let us never forget that for every message we intend to give, the values, beliefs, and previous experiences of those on the receiving end will play a key role in how the message is interpreted.
Effective communication, the kind that enhances the relationship, should be a patient-centered approach that elicits, understands, and validates the patient’s experience within his or her own cultural and psychological context; reaches a shared understanding of the patient’s problem and treatment; and empowers the patient by offering meaningful involvement in choices about their care.5
One of the greatest challenges of this era in health care is to preserve the interpersonal relationship with our patients in an environment that is driven by business, standardization, and large systems of care that focus on population health rather than individual patients. To uphold the human connection with our patients, surgeons must improve their communication skills.
Although there is substantial evidence in the literature regarding the effects that a positive physician-patient relationship has on patients, very little has been written on the great influence that this bond has on physician well-being.
Those of us who chose to become health care professionals are exposed to emotional turmoil repeatedly throughout our careers. Patient tragedies of all kinds—due to violence, trauma, cancer, and so on—can affect the most resilient among us.
Indeed, studies that have examined physician well-being have concluded that approximately 30 percent of all practicing physicians in this country are suffering from burnout.6,7 To avoid this emotional rollercoaster, some have suggested that physicians should remain personally and emotionally detached from their patients.
On the contrary, I would argue that establishing a meaningful connection with patients and colleagues in the organization is one of the most powerful deterrents to physician burnout, and the satisfaction derived from these relationships provides context, meaning, and purpose to our lives.
Similarly, these improved relationships will have a positive impact across the organization. The members of our teams are always watching our actions.
When they see someone who leads by example—delivering on promises, caring for patients, being approachable, listening—they develop a sense of inner peace and satisfaction and a desire to contribute to the excellent work of the group.
This facilitates the development of high performing teams—teams that share a common purpose and that pursue lofty goals in the care of their patients.
Most of us don’t view surgical practice as a job. We view it as a calling. The passion and sense of purpose that drives physicians connects us with our patients in a way that reassures and inspires them.
At the same time, it is important to emphasize that clinician well-being and self-awareness have a powerful effect on our ability to communicate better, which in turn will improve the interpersonal relationships that drive patient satisfaction and behavior.
A clinician’s mental well-being is a precondition for being effective in the delivery of care and in recognizing and valuing the patient’s perspective as distinct from one’s own.8
Keeping the arch stable for a rewarding career
I have described the importance of building trust through communications, primarily in the context of the practice of medicine.
In every encounter with our patients, our teams, or for that matter, with ourselves, our own souls, we have a unique opportunity to do good—to make someone feel better or to improve the image of our workplace—and allow us to build trust, no matter how small or how big the opportunity or the result may be.
I invite you to reflect on this simple statement, and if you believe it, if you see yourself using each encounter to affix that keystone that ensures the integrity of the arch described earlier, then I say to you: do it. Be present.
Seize each opportunity to do what your heart tells you is the right thing to do at every turn of that long, winding road that we call life. That way when you reach the sunset of your career, you will feel as if you lived and as if your life mattered—to you, to your patients, to your team, and to humanity at large.
- Trust. 2016. Merriam-Webster.com. Available at: www.merriam-webster.com/dictionary/trust. Accessed November 23, 2016.
- Pellegrino ED, Thomasma DC. Fidelity of Trust. The Virtues in Medical Practice. Oxford, U.K. Oxford University Press, 1993. 65-83.
- Caterinicchio RP. Testing plausible path models of interpersonal trust in patient-physician treatment relationships. Soc Sci Med. 1979;13A(1):81-99.
- Thom DH, Wong ST, Guzman D, et al. Physician trust in the patient: Development and validation of a new measure. Ann Fam Med. 2011;9(2):148-154.
- Epstein RM, Franks P, Fiscella K, et al. Measuring patient-centered communication in patient-physician consultations: Theoretical and practical issues. Soc Sci Med. 2015;61(7):1516-1528.
- Shanafelt TD, Balch CM, Bechamps GJ, et al. Burnout and career satisfaction among American surgeons. Ann Surg. 2009;250(3):463-471.
- Shanafelt TD, Balch CM, Bechamps G, et al. Burnout and medical errors among American surgeons. Ann Surg. 2010;251(6):995-1000.
- Chochinov HM, McClement SE, Hack TF, et al. Healthcare provider communication: An empirical model of optimal therapeutic effectiveness. Cancer. 2013;119:1706-1713.