OVERVIEW

The doctor-patient relationship—despite all the pressures of managed care, bureaucratic intrusions, and other systemic complications—remains one of the most profound partnerships in the human experience; in it, one person reveals to another his or her innermost concerns, in hope of healing.^1,2 In this deeply intimate relationship, when we earn our patients’ trust, we are privileged to learn about fears and worries that our patients may not have shared—or ever will share—with another living soul; they literally put their lives and well-being in our hands. For our part, we hope to bring to this relationship technical mastery of our craft, wisdom, experience, and humility and our physicianly commitment to stand by and with our patient—that is, not to be driven away by any degree of pain, suffering, ugliness, or even death itself. We foreswear our own gratification, beyond our professional satisfaction and reward, to place our patients’ interests above our own. We hope to co-create a healing relationship, in which our patients can come to understand with us the sources of suffering and the options for care and healing, and partner with us in the construction of a path toward recovery.

In clinical medicine, the relationship between doctor and patient is not merely a vehicle through which to deliver care. Rather, it is one of the most important aspects of care itself. Excellent clinical outcomes—in which patients report high degrees of satisfaction, work effectively with their physicians, adhere to treatment regimens, experience improvements in the conditions of concern to them, and proactively manage their lives to promote health and wellness—are far more likely to arise from relationships with doctors that are collaborative, and in which patients feel heard, understood, respected, and included in treatment planning.^3–6 On the other hand, poor outcomes—including “noncompliance” with treatment plans, complaints to oversight boards, and malpractice actions—tend to arise when patients feel unheard, disrespected, or otherwise out of partnership with their doctors.^7–9 Collaborative care not only leads to better outcomes, but it is also more efficient than noncollaborative care in achieving good outcomes.^10,11 The relationship matters.

An effective doctor-patient relationship may be more critical to successful outcomes in psychiatry (because of the blurred boundaries between the conditions from which patients suffer and the sense of personhood of the patients themselves) than it is in other medical specialties. In psychiatry, more than in most branches of medicine, there is a sense that when the patient is ill, there is something wrong with the person as a whole, rather than that the person “has” or suffers from a discrete condition. Our language aggravates this sense of personal defectiveness or deficiency in psychiatric illness. We tend to speak of “being depressed,” “I am bipolar,” or “he is schizophrenic,” as if these were qualities of the whole person rather than a condition to be dealt with. Even more hurtfully, we sometimes speak of people as “borderlines,” or “schizophrenics,” as if these labels summed up the person as a whole. This language, together with the persistent stigma attached to mental illness in our culture, amplifies the wary sense of risk of shame and humiliation that patients may experience in any doctor-patient interaction,¹² and makes it even more imperative that the physician work to create conditions of safety in the relationship.

Moreover, if we seek to co-create a healing environment in which the patient feels deeply understood (as a basis for constructing a path toward recovery), psychiatry more than perhaps any branch of medicine requires us to attend thoughtfully to the whole person, even to parts of the person’s life that may seem remote from the person’s areas of primary concern. So many psychiatric conditions from which people suffer have, in addition to important biological aspects, critically important contributions from the person’s current relationships and social environment, from psychological issues from the past, and from the person’s spiritual life and orientation. Much of the time, these psychological, social, or spiritual aspects of the person shed vitally important light on the nature of the person’s distress, and are often crucial allies in recovery. There must be time and space in the doctor-patient relationship to know the whole person.¹³ An appreciation of the person from the perspective of the person’s biological ailments and vulnerabilities; the person’s social connections, supports, and stressors in current time; the person’s psychological issues from the past; and how the person spiritually makes sense of a life lived with the foreknowledge of death—these four models can give us a sense of the person in depth.¹⁴

THE OPTIMAL HEALING ENVIRONMENT: PATIENT-CENTERED CARE

Although there may be cultural factors that limit the validity of this generalization, in the main patients strongly prefer care that centers on their own concerns; addresses their perspective on these concerns; uses language that is straightforward, is inclusive, and promotes collaboration; and respects the patient as a fully empowered partner in decision-making.^15–17 This model of care may be well denoted by the term patient-centered care^10,18,19 or, even better, relationship-centered care. In Crossing the Quality Chasm, the Institute of Medicine identified person-centered practice as a key to achieving high-quality care that focuses on the unique perspective, needs, values, and preferences of the individual patient.²⁰ Person-centered care involves a collaborative relationship in which two experts—the practitioner and the patient—attempt to blend the practitioner’s knowledge and experience with the patient’s unique perspective, needs, and assessment of outcome.¹⁷

The shift to patient-centered care in part may have been fueled by the women’s movement,²¹ as women have found their voice and awakened the culture to the reality of disempowering people and oppressing people through tyrannies of role and language. Moreover, the women’s movement resulted in a paradigmatic shift in the healing professions, in which the perspectives of both parties have an equal claim on legitimacy and importance, and in which the relationship itself has a deep and pressing value for the outcome of any enterprise. The rise of consumerism and the wide dissemination of information on the Internet have also contributed to an emergence of more empowered patients as consumers.²¹ Rapid shifts in insurance plans, as employers seek to manage ever-rising health care costs, have led patients to shift practitioners with greater frequency, reinforcing the “informed shopper” approach to “patienthood.” As Lazare and colleagues²² presciently noted more than 30 years ago, patients increasingly view themselves as customers, and seek value, which is always in the eye of the beholder.

Quill and Brody²⁰ described a model of doctor-patient interaction that they termed enhanced autonomy. It described a relationship in which the patient’s autonomous right to make critical decisions regarding his or her own care was augmented by the physician’s full engagement in dialogue about these decisions (including the physician’s input, recommendations, and open acknowledgment of bias, if present). Quill and Brody pointed out that in purely autonomous decision-making, which they denoted as the “independent choice” model, there is a sort of perversion of patient-centeredness, in which the patient is essentially abandoned to make critical decisions without the benefit of the physician’s counsel. In this model, physicians see their role as providing information, options of treatment, and odds of success; answering questions objectively; and eschewing recommendations (so as not to bias the patient or family). They noted that some physicians may (mistakenly) believe that such “objective” advice shields them from lawsuits (if bad outcomes follow from treatments chosen purely by the patients themselves).

In relationship-centered practice, more than patient-centered practice, the physician does not cede decision-making authority or responsibility to the patient and family, but rather enters into real dialogue about what the physician thinks is best. Most patients and families seek a valued doctor’s answer to the question (stated or not), “What would you do if this were your family member?” This transparent and candid collaboration shares power rather than cedes it, and conveys respect and concern. Enhanced autonomy involves a commitment to know the patient deeply, and to respect the patient’s wishes; to share information as openly and as honestly as the patient desires; to involve others at the patient’s direction; and to treat the patient as a full partner to the greatest extent possible.

In patient-centered care, there is active management of communication to avoid inadvertently hurting, shaming, or humiliating the patient through careless use of language or other slights. When such hurt or other error occurs, the practitioner apologizes clearly and in a heartfelt way to restore the relationship.²³

The role of the physician in patient-centered care is one of an expert who seeks to help a patient co-manage his or her health to whatever extent is most comfortable for that particular person. The role is not to cede all important decisions to the patient, whether he or she wants to participate in these decisions or not.²⁰

The patient-centered physician attempts to accomplish six processes. First, the physician endeavors to create conditions of welcome, respect, and safety, so that the patient can reveal his or her concerns and perspective. Second, the physician endeavors to understand the patient deeply, as a whole person, listening to both the words and the “music” of what is communicated. Third, the physician confirms and demonstrates his or her understanding through direct, nonjargonistic language to the patient. Fourth, if the physician successfully establishes common ground on the nature of the problem as the patient perceives it, an attempt is made to synthesize these problems into workable diagnoses and problem lists. Fifth, using expertise, technical mastery, and experience, a path is envisioned toward healing, and it is shared with the patient. Finally, together, the physician and patient can then negotiate about what path makes the most sense for this particular patient.

Through all of this work, the physician models and cultivates a relationship that values candor, collaboration, and authenticity; it should be able to withstand conflict—even welcoming conflict as a healthy part of human relationships.²⁴ In so doing, the physician-patient partnership forges a relationship that can stand the vicissitudes of the patient’s illness, its treatment, and conflict as it arises in the relationship itself. In this way, the health of the physician-patient relationship takes its place as an important element on every problem list, to be actively monitored and nurtured as time passes.

COLLABORATING AROUND HISTORY-TAKING

One major goal of an initial interview is to generate a database that will support a comprehensive differential diagnosis. However, there are other overarching goals. These include demystifying and explaining the process of collaboration, finding out what is troubling and challenging the patient, co-creating a treatment path to address these problems, understanding the person as a whole, encouraging the patient’s participation, welcoming feedback, and modeling a mindful appreciation of the complexity of human beings (including our inner emotional life).^35,36 At the end of the history-taking—or to use more collaborative language, after building a history with the patient³⁷—a conversation should be feasible about paths toward healing and the patient’s and doctor’s mutual roles in that process (in which the patient feels heard, understood, confident in the outcome, and committed to the partnership).

PLANNING THE PATH FORWARD: CREATING A CLINICAL FORMULATION

Having heard the patient’s story, the next challenge is to formulate an understanding of the person that can lead to a mutually developed treatment path. A formulation is not the same thing as a diagnosis. A diagnosis describes a condition that can be reasonably delineated and described to the person and that implies a relatively foreseeable clinical course, and usually implies options of courses of treatment. As important as a diagnosis is in clinical medicine, a diagnosis alone is insufficient for effective treatment planning, and is an inadequate basis for work by the doctor-patient dyad.

In psychiatry, one method for creating a formulation is to consider each patient from a bio-socio-psycho-spiritual perspective, thinking about each patient from each of four perspectives.¹⁴ The first of these is biological: Could the person’s suffering be due, entirely or in part, to a biological condition of some sort (either from an acquired condition [such as hypothyroidism] or a genetic “chemical imbalance” [such as some forms of depression and bipolar disorder])? The second model is social: Is there something going on in the person’s life that is contributing to his or her suffering, such as an abusive relationship, a stressful job, a sick child, or financial trouble? The third model is psychological: Although this model is more subtle, most patients will acknowledge that practically everyone has “baggage” from the past, and sometimes this baggage contributes to a person’s difficulties in the present. The fourth model is spiritual: Although this model is not relevant for all people, sometimes it is very important. For people who at one point had faith but lost it, or for whom life feels empty and meaningless, conversation about the spiritual aspects of their suffering sometimes taps into important sources of difficulty and sometimes into resources for healing.⁴³

These four models—biological “chemical imbalances,” current social stressors, psychological baggage from the past, and spiritual issues—taken together provide an excellent framework for understanding most people. One of the beauties of this method is that these models are not particularly pathologizing or shame-inducing. On the contrary, they are normalizing, and emphasize that all of us are subject to these same challenges. This opens the way to collaboration.

Whereas the biological, social, and spiritual models are fairly easy to conceptualize, the formulation of psychological issues can seem particularly daunting to physicians and to patients alike, since every person is dizzyingly complex. It can seem almost impossible to formulate a psychological perspective of a person’s life that is neither simplistic and jargon-ridden, nor uselessly complex (and often jargon-ridden!). A useful method for making sense of the psychological aspects of the person’s life is to consider whether there are recurrent patterns of difficulty, particularly in important relationships as the person looks back on his or her life.¹⁴ To gather information to assess this model, most useful is information about the most important relationships in this person’s life (in plain, nontechnical terms—not only current important relationships, such as we need to assess current social function, but also who have been the most important people in the person’s life over time). In this way, for example, it may become clear that the person experienced his relationship with his father as abusive and hurtful, and has not had a relationship with any other person in authority since then that has felt truly helpful and supportive. This in turn may shed light on the person’s current work problems, and may illuminate some of the person’s feelings of depression.

Underlying our inquiry regarding whether there may be significant recurrent patterns in the person’s life that shed light on his or her current situation is the critical notion that these patterns almost always began as attempts to cope, and represent creative adaptations, or even strengths. Often, these patterns—even when they involve self-injury or other clearly self-destructive behaviors—began as creative solutions to apparently insoluble problems. For example, self-injury may have represented a way of mastering unbearable feelings, and may have felt like a way of being in control, while remaining alive under unbearable circumstances. It is important that the doctor appreciate that most of the time these self-defeating behaviors began as solutions, and often continue to have adaptive value in the person’s life. If we fail to appreciate the creative, adaptive side of the behavior, the person is likely to feel misunderstood, judged harshly, and possibly shamed.

Practically everyone finds the four models understandable and meaningful. Moreover, and importantly, these four models avoid language that overly pathologizes the person, and they use language that tends to universalize the patient’s experience. This initial formulation can be a good platform for a more in-depth discussion of diagnostic possibilities. With this framework, the differential diagnosis can be addressed from a biological perspective, and acute social stressors can be acknowledged. The diagnosis and treatment can be framed in a manner consistent with the person’s spiritual orientation. Fleshing out the psychological aspects can be more challenging, but this framework creates a way of addressing psychological patterns in a person’s life and his or her interest in addressing them and their ability to address them.

TREATMENT PLANNING

Having a good formulation as a frame for a comprehensive differential diagnosis permits the doctor and the patient to look at treatment options (including different modalities, or even alternative therapies or solutions not based in traditional medicine). It is possible from this vantage point to look together at the risks and benefits of various approaches, as well as the demands of different approaches (the time and money invested in psychotherapy, for example, or the side effects that are expectable in many medication trials). The sequence of treatments, the location, the cost, and other parameters of care can all be made explicit and weighed together.

This approach also is effective in dealing with situations in which the physician’s formulation and that of the patient differ, so that consultation and possibly mediation can be explored.¹⁴ For example, the physician’s formulation and differential diagnosis for a person might be that the person’s heavy drinking constitutes alcohol abuse, or possibly dependence, and that cessation from drinking and the active pursuit of sobriety is a necessary part of the solution to the patient’s chronic severe anxiety and depression. The patient, on the other hand, may feel that if the doctor were offering more effective treatment for his anxiety and depression, he would then be able to stop drinking. An explicit formulation enables the patient and the doctor to see where, and how, they disagree, and to explore alternatives. For example, in the case cited, the physician could offer to meet with family members with the patient, so both could get family input into the preferred solution; or the physician could offer the patient a referral for expert psychopharmacological consultation to test the patient’s hypothesis.

In either case, however, the use of an explicit formulation in this way can identify problems and challenges early in the evaluation phase, and can help the physician avoid getting involved in a treatment under conditions likely to fail. Mutual expectations can be made clear (e.g., the patient must engage in a 12-step program, get a sponsor, and practice sobriety for the duration of the treatment together) and the disagreement can be used to forge a strong working relationship, or the physician and patient may agree not to work together.

The formulation and differential diagnosis are of course always in flux, as more information becomes available and the doctor and patient come to know each other more deeply. Part of the doctor’s role is to welcome and nurture, to change, and to promote growth, to allow the relationship to grow as part of the process.¹⁴

OBSTACLES AND DIFFICULTIES IN THE DOCTOR-PATIENT RELATIONSHIP

Lazare and colleagues²² pioneered the patient’s perspective as a customer of the health care system. Lazare¹² subsequently addressed the profound importance of acknowledging the potential for shame and humiliation in the doctor-patient encounter, and most recently has written a profound treatise on the nature and power of true, heartfelt apology.²³ Throughout his work, Lazare has addressed the inevitable occurrence of conflict in the doctor-patient relationship (as in all important human relationships) and offered wise counsel for negotiating with the patient as a true partner to find creative solutions.⁴⁴

Conflict and difficulty may arise from the very nature of the physician’s training, language, or office environment. Physicians who use overly technical, arcane, or obtuse language distance themselves and make communication difficult. Similarly, physicians may lose sight of how intimidating, arcane, and forbidding medical practice—perhaps especially psychiatry—can appear to the uninitiated, unless proactive steps toward demystification occur. Similarly, over-reliance on “objective” measures, such as symptom checklists, questionnaires, tests, and other measurements, may speed diagnosis, but may alienate patients from effective collaboration. More insidious may be assumptions regarding the supposed incapacity of psychiatric patients to be full partners in their own care. Hurtful, dismissive language, or a lack of appreciation for the likelihood that a patient has previously experienced hurtful care, may damage the relationship.¹⁵ Overly brief, symptom-focused interviews that fail to address the whole person, as well as his or her preferences, questions, and concerns, are inadequate foundations for an effective relationship.

Conflict may also arise from the nature of the problem to be addressed. In general, patients are interested in their illness—how they experience their symptoms, how their health can be restored, how to ameliorate their suffering—whereas physicians are often primarily concerned with making an accurate diagnosis of an underlying disease.⁴⁵ Moreover, physicians may erroneously believe that the patient’s “chief complaint” is the one that the patient gives voice to first, whereas patients often approach their doctors warily, not leading with their main concern, which they may not voice at all unless conditions of safety and trust are established.⁴⁶ Any inadvertent shaming of the patient makes the emergence of the real concern all the less likely.¹²

Physicians may misunderstand a patient’s readiness to change and may assume that once a diagnosis or problem is identified, the patient is prepared to work to change it. In actuality, a patient may be unable or unwilling to acknowledge the problem that is obvious to the physician, or, even if able to acknowledge it, may not be prepared to take serious action to change it. Clarity about where the patient is in the cycle of change^47,48 can clarify such misunderstanding and help the physician direct his or her efforts at helping the patient become more ready to change, rather than fruitlessly urging change to which the patient is not committed. Similarly, physicians may underestimate social, psychological, or spiritual aspects of a person’s suffering that complicate the person’s willingness or ability to partner with the physician toward change. A deeply depressed patient, for example, whose sense of shame and worthlessness is so profound that the person feels that he or she does not deserve to recover, may be uncooperative with a treatment regimen until these ideas are examined in an accepting and supportive relationship.

Conflict may arise, too, over the goals of the work. Increasingly, mental health advocates and patients promote “recovery” as a desired outcome of treatment, even for severe psychiatric illness. Working toward recovery in schizophrenia or bipolar disorder, which most psychiatrists regard as lifelong conditions that require ongoing management, may seem unrealistic or even dishonest.⁴⁹

It may be useful for physicians to be aware that the term recovery is often used in the mental health community to signify a state of being analogous to recovery from alcoholism or other substance abuse.⁵⁰ In this context, one is never construed to be a “recovered” alcoholic, but rather a “recovering” alcoholic—someone whose sobriety is solid, who understands his or her condition and vulnerabilities well, takes good care of himself or herself, and is ever alert to risks of relapse, to which the person is vulnerable for his or her entire life.

In a mental health context, “recovery” similarly connotes a process of reclaiming one’s life, taking charge of one’s options, and stepping out of the position of passivity and victimization that major mental illness can often involve, particularly if it involves involuntary treatment, stigmatization, or downright oppression. From this perspective, re-covery means moving beyond symptomatic control of the disease to having a full life of one’s own design (including work, friends, sexual relationships, recreation, political engagement, spiritual involvement, and other aspects of a full and challenging life).

Other sources of conflict in the doctor-patient relationship may include conflict over methods of treatment (a psychiatrist, perhaps, who emphasizes medication to treat depression to the exclusion of other areas of the patient’s life, such as a troubled and depressing marriage), over the conditions of treatment (e.g., the frequency of appointment, length of appointment, or access to the physician after hours), or over the effectiveness of treatment (e.g., the psychiatrist believes that antipsychotic medications restore a patient’s function, whereas the patient believes the same medications create a sense of being drugged and “not myself”).¹⁷

In these examples, as in so many challenges on the journey of rendering care, an answer may lie not solely in the doctor’s offered treatment, nor in the patient’s “resistance” to change, but in the vitality, authenticity, and effectiveness of the relationship between them.