DOCTOR-PATIENT
RELATIONSHIP (DPR) IN THE MODERN WORLD
J.C MEEROFF MD, PhD Clinical Associate Prof of Medicine, FAU
SUSANA MEEROFF Director of Health Services and
Administration,
South Florida Institute of Integrative
Medicine
“People pay the doctor
for his trouble; for his kindness they still remain in his debt”. Seneca the
Young
“Always treat the
patient not the laboratory numbers”. Prof Dame Sheila P V Sherlock
“There are only
two sorts of doctors: those who practice with their brains, and those who
practice with their tongues”. William Osler
"It is more
important to know what sort of person has a disease than to know what sort of
disease a person has." Hippocrates
“In a pathetic
society a bad doctor is one who if you are not sick, makes you sick”. J.C.
Meeroff
"Man is the only animal for whom his own existence is a problem which he has to solve.” Erich Fromm
"There are no small problems. Problems that appear small are large problems that are not understood" Santiago Ramon y Cajal
INTRODUCTION
The doctor-patient
relationship (DPR) is a crucial but poorly understood topic. DPR is a
reciprocal connection between a doctor and a patient very much influenced by economical,
ethical, political, social, and legal factors/issues.
The DPR can
be defined as a consensual relationship in which
the patient knowingly seeks the physician's assistance and in which
the physician consciously accepts the person as a patient. At its
core, the DPR represents a fiduciary relationship of humanitarian
trust.
The DPR is the
foundation for clinical care and can have profound positive or negative
implications on clinical results. Ultimately the central goal of the DPR is to
improve patient health outcomes and the quality of medical care. Stronger DPR
are correlated with improved clinical results. Therefore, as the relationship
between physicians and patients becomes prominent, it is essential to
understand the factors that influence this relationship.
It is safe to say that
there are four important elements necessary to construct this relationship.
They are:
1. medical knowledge,
2. psychosocial and ethnic closeness,
3. trust, and
4. availability for longitudinal care.
Unfortunately, in the contemporary
healthcare state of affairs, very seldom it is feasible to secure all these four
components in order to create a valuable DPR.
CURRENT
STATUS OF HEALTHCARE
In pre-industrial and
early industrial times medical services were unsophisticated involving only two
players: the doctor and the patient. Similarly, to what occurred in the rest of
the world in the US before healthcare plans emerged, patients would
simply pay for medical services out of their pocket. Now the situation had
changed since the progress of medical science and technology, the exponential
population growth and the corporatization of the so called “medical industry”
introduced a new player in the delivery of medical services: the bureaucracy of
the managed care systems.
In the late 1900s and
the first part of the XX century early healthcare plans emerged. They had two main
modalities: private and public systems. One of the earliest examples of an
HMO was a 1910 prepaid group plan in Tacoma, Washington for lumber mills owners
and their employees who paid 50 cents a month for medical coverage. Soon after, Blue
Cross (hospital care) and Blue Shield (professional service) plans began
(BC/BS). For example in 1929 a BC/BS prepaid plan started in Dallas, Texas
with Baylor Hospital, a system that later spread to other hospitals. These plans
were largely independent of each other and controlled by statewide hospitals
and their physicians until the 1970s, when they became nation-wide nonprofits organizations
before being converted into for-profit corporations
Currently manage care,
in all many different modalities(HMOs, PPOs, etc.) has become the almost
exclusive system of delivering and receiving health care in the western world. Regrettably managed care presents
more challenges than opportunities for effective communication between doctors and
patients. In many instances the managed care environment limits the patient’s access
to medical services, lower the time that physicians can devote to attend
patients, fail to cover for some medical costs, harm the possibility of
continuity of care and reduce reimbursements for doctor’s work, all factors
that might impair the delivery of quality healthcare.
CONTEMPORARY MODES OF DPR
Throughout history there has been much debate regarding
the ideal DPR. In 1992, Ezekiel and Linda Emanuel proposed four models for the physician-patient relationship: the paternalistic model, the interpretive model, the deliberative
model, and the informative model. These models differ among themselves based on
the understanding of four key principles: 1. the goals of the physician-patient
interactions, 2. the physician’s obligations, 3. the patient’s values, and 4. the patient’s
autonomy.
Within the patient centered model of Medicine and
following Balint original ideas of shared decision-making as well as Emanuel’s
classification of DPR, we presently recognize 4 different styles of DPR. They
are:
Dominating mode (DM). Also known as paternalistic mode . In the DM the doctor acts in an
autocratic fashion making a quick heuristic clinical diagnosis and prescribes an
undisputed form of treatment. In this model the relationship is vertical: the
doctor acts as a guardian and the patient is just a passive receptor of medical
actions.
Consumeristic mode (CM). Here the patient has a definitive concept of needs since she/he has
already decided on a diagnosis and demands from the doctor to receive the
treatment she/he consider the best. In the CM the patient is utterly in charge
of the decision making for the medical condition and the doctor simply plays the
role of an expert salesman.
Informative mode (IM). Here the doctor gives educated evidence to a patient who already has a partial
idea about her/his medical condition and the possible form of treatment. In the
IM the doctor acting as a counselor capable of providing enough information, can
modify the patient attitude in order to enter a different mode of DPR.
Participative mode (PM). Here the doctor and the patient review the diagnostic and therapeutic
options and arrive to a plan that is accepted by both. In the PM the
relationship is horizontal (mutual participation and respect) and the patient
must play an active role in the implementation of the medical treatment. In the
PM there is an alliance between the
doctor and the patient, based on cooperation rather than confrontation, in
which the doctor must understand
the patient as a unique human being and the patient must accept
the doctor as an educated partner. In this mode the doctor is a teacher and
there is a shared decision-making that replaces patient
passivity.
Table 1 The 4 models of DPR according to
Emanuel (modified from Emanuel & Emanuel)
|
Model |
Dominating |
Informative |
Consumeristic |
Participative |
|
|
|
|
|
|
|
Patient values |
Subjective |
Conflicting |
Open |
Objective |
|
|
|
|
|
|
|
Patient Autonomy |
None |
Partial |
Total |
Complete |
|
|
|
|
|
|
|
MD obligation |
Providing |
Elucidative |
Persuasive |
Reasonable |
|
|
|
|
|
|
|
MD role |
Guardian |
Counselor |
Expert salesman |
Partner |
We argue that all four modes have valid reasons to be applied
according to the circumstances in which the DPR is initiated. However, in ideal
conditions, we give preference to the PM since it actively engages the patient
in her/his medical treatment. Nevertheless, the other forms of DPR are useful
in circumstances where there are limits imposed by special conditions in which
the doctor and the patient interact such as in emergencies, in plastic and
cosmetic surgeries, in pediatrics, etc.
THE PROBLEM WITH CONSUMERISTIC
MEDICINE
In the contemporary western medical system, healthcare
continues to take a strong consumeristic vision where the economic interests of
the insurance companies are considered first. Insurance companies are concerned
in providing services at reduced cost. Furthermore, today’s patients are not
simply looking to visit their doctors to find cure for a disease, but also to
purchase bargain medical services for their own gratification. Inappropriately,
in consumeristic medicine, doctors are downgraded to the role of “providers” and
very seldom can they create a long lasting DPR. Between the asphyxiating regulatory
demands imposed by the managed care bureaucracy, the financial interests of the
medical industry and the patient desires to control the interpersonal
relationships, “providers” can find that it is very difficult to use the preferred
PM DPR.
As it happens in supermarket merchandise stores, the “provider”
can’t choose their patients, nor they have enough time to establish a long
lasting DPR. Patients have limited instances for medical visits (now called
“encounters”) and there is very seldom the possibility of continuity of care since
patients very commonly are forced to change medical plans and/or change
physicians.
Contemporary medical doctors that are pressed by time,
space and financial constrains that result from the dependency on insured/prepaid/social
medicine are most of the time resorting to persuasion heuristics (using the DM DPR)
to quickly form judgments, make decisions and find solutions to every day’s medical problems. This situation not only limits
the possibility but also endangers the opportunity for an optimal DPR.
Limiting DPR to a single option that is CM DPR where
patient satisfaction despite optimal medical outcomes is the golden rule, a
concept borrowed from shopping consumerism where the catchphrase “the client is
always right” is dominant. Most of the time the acceptance of a CM DPR severely
damages the possibility of building a valuable connection with patients and, in
response to such threat, doctors protect themselves by using the DM DPR
indiscriminately.
We must understand that consumeristic Medicine, while
solving some important issues such as improving access to care and lowering
some costs, is not always right. Several arguments must be considered as
follows:
1 Doctors are not omnipotent “providers” and some
“clients” are confrontational, rude, malicious or petulant and almost
impossible to be satisfied. Therefore, Medicine should not depend on individual
“clients”.
2. Most “clients” are not omniscient but those who
pretend to be corner doctors demanding actions that may not be good medical practices
and/or are not in their own best interest.
3. Consumerism attitude attempts against PM DPR especially
when a disgruntled “client” demoralizes and distress out the doctor.
CONCLUSIONS
At the time medical experts are still debating if
Medicine is a science, an art or a business and economists and politicians are
trying to find out the best medical system to offer good healthcare for the
entire population we, western educated doctors, are trying to understand the
scope and mechanisms of the doctor-patient relationship (DPR). In the
patient-centered model of medical care different modes of DPR are available.
They permit to approach the interpersonal connection according to the special settings
in which the DPR is created.
SELECTED
REFERENCES
Balint M. (1964) The doctor, his patient and the illness. Pittman Medical, London
Balint, M. et al.(1993) The doctor, the patient and the group Balint revisited Routledge, London
Emanuel EJ and Emanuel LL (1992) JAMA 267(16):2221-2226. doi:10.1001/jama.1992.03480160079038
Hall JA. Et al. (2002). The physician–patient relationship. Pat. Educat & Coun; 48:69-77
Kaba R
& Sooriahumaram P. (2007) The evolution of the doctor-patient
relationship. Int J of Surg 5: 57-65
Thomasma DC. (1983) Beyond Medical Paternalism and Patient Autonomy: A
Model of Physician Conscience for the Physician-Patient Relationship. Ann Int
Med 98:243-248
Copyright 2020 © JCMeeroff, MD,
PhD. All rights reserved.
How to
cite this article
MEEROFF JC & MEEROFF S (2020). Doctor-patient relationship in the modern world https://www.meeroffmedicine.com/articles/The Doctor-Patient relationship
No comments:
Post a Comment