1: The Doctor-Patient Relationship

Published on 24/05/2015 by admin

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CHAPTER 1 The Doctor-Patient Relationship

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.36 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.79 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.1517 This model of care may be well denoted by the term patient-centered care10,18,19 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.

Physician Practice in Patient-Centered Care

Physicians’ qualities have an impact on the doctor-patient relationship. These qualities support and enhance—but are not a substitute for—technical competence and cognitive mastery. Perhaps most important is a quality of mindfulness,25 a quality described by Messner26 as one acquired through a process of constant autognosis, or self-awareness. Mindfulness appreciates that a person’s emotional life (i.e., of both the physician and the patient) has meaning and importance and it deserves our respect and attention. Mindfulness connotes a commitment to respectful monitoring of one’s own feelings, as well as to the feelings of the patient, and acceptance of feelings in both parties without judgment and with the knowledge that feelings are separate from acts.

Mindfulness, which springs from roots in Buddhism,27 has offered much wisdom to the practice of psychotherapy (e.g., helping patients tolerate unbearable emotions without action, and helping clinicians tolerate the sometimes hideous histories their patients share with them).28 Mindfulness helps physicians find a calm place from which to build patient relationships.29 Mindfulness counsels us to attend to our feelings with acceptance and compassion and to those of our patients, without a compulsion to act on these feelings. Thus, the physician can be informed by the wealth of his or her inner emotional life, without being driven to act on these emotions; this can serve as a model for the relationship with the patient.

Other personal qualities in the physician that promote healthy and vibrant relationships with patients include humility, genuineness, optimism, a belief in the value of living a full life, good humor, candor, and transparency in communication.30

Important communication skills include the ability to elicit the patient’s perspective; help the patient feel understood; explain conditions and options in clear, nontechnical language; generate input and consensus about paths for-ward in care; acknowledge difficulty in the relationship without aggravating it; welcome input and even conflict; and work through difficulty, to mutually acceptable, win-win solutions.31

Practical considerations in physicians’ practice include clarity on the part of the physician and the patient on mutual roles, expectations, boundaries, limitations, and contingencies (e.g., how to reach the physician or his or her coverage after hours and under what conditions, and the consequences of missed appointments).32,33 Many physicians address these concerns in a “welcome to my practice” letter that sets out the parameters of the professional relationship. Many problems—and lawsuits—arise from misunderstanding about what the physician can and cannot do, and will and will not do, in the process of treating a patient.

One of the most important ingredients to successful doctor-patient relationships (that is in terribly short supply) is time.34 There is simply no substitute or quick alternative to sitting with a person and taking the time to get to know that person in depth, and in a private setting free from intrusions and interruptions. To physicians who practice in high-volume clinics, with beepers beeping, phones ringing, and patients scheduled every few minutes, this may seem an impossible scenario. However, most physicians know that what we want when we or a loved one is ill is the full and undivided attention of our doctor; patients in this regard are no different than physicians.