There is considerable healing power in the physician-patient alliance. Working together offers the opportunity to significantly improve the patient's quality of life and health status. This therapeutic alliance involves specific and important physician obligations.
What is a fiduciary relationship?
Fiduciary derives from the Latin word for "confidence" or "trust". The bond of trust between the patient and the physician is vital to the diagnostic and therapeutic process. It forms the basis for the physician-patient relationship. In order for the physician to make accurate diagnoses and provide optimal treatment recommendations, the patient must be able to communicate all relevant information about an illness or injury. Physicians are obliged to refrain from divulging confidential information. This duty is based on accepted codes of professional ethics, which recognize the special nature of physician-patient relationships.
How has the physician-patient relationship evolved?
The historical model for the physician-patient relationship involved patient dependence on the physician's professional authority. Believing that the patient would benefit from the physician's actions, a paternalistic model of care developed. Patient's preferences were generally not elicited, and were over-ridden if they conflicted with the physician’s convictions about appropriate care.
During the second half of the twentieth century, the physician-patient relationship has evolved towards shared decision making. This model respects the patient as an autonomous agent with a right to hold views, to make choices, and to take actions based on personal values and beliefs. Patients are acknowledged to be entitled to weigh the benefits and risks of alternative treatments, including the alternative of no treatment, and to select the alternative that best promotes their own values (for further discussion, see Informed Consent).
Will the patient trust me if I am a student?
Students may feel uncertain about their role in patient care. Building trust requires honesty: students must be honest about their role, letting the patient know s/he is a physician-in-training. In some settings, an attending physician or resident can introduce the student to initiate a trusting relationship. In other settings, students may need to introduce themselves. One form of introduction would be "Hello, I am Mary Jones. I'm a third year medical student who is part of the team that will be caring for you during your hospitalization. I'd like to hear about what brought you into the hospital." (For further discussion of this issue, see Student Issues.)
Many patients appreciate the opportunity to work with the student on the team. Students usually have more time to spend with a patient, listening to the patient's history and health concerns, and may become more aware of personal concerns than other team members. Patients notice and appreciate this extra attention.
How much of herself should the physician bring to the physician-patient relationship?
Many patients may feel more connected to a physician when they know something of the physician’s life, and it may sometimes be appropriate to share information about family or personal matters. However, it is essential that the patient, and the patient's concerns, be the focus of every visit.
What role should the physician's personal feelings and beliefs play in the physician-patient relationship?
Occasionally, a physician may face requests for services, such as contraception or abortion, which raise a conflict for the physician. Physicians do not have to provide medical services in opposition to their personal beliefs. In addition, a nonjudgmental discussion with a patient regarding her need for the service and alternative forms of therapy is acceptable. However, it is never appropriate to proselytize. While the physician may decline to provide the requested service, the patient must be treated as a respected, autonomous individual. Where appropriate, the patient should be provided with information about how to obtain the desired service.
What can hinder physician-patient communication?
There may be many barriers to effective physician-patient communication. Patients may feel that they are wasting the physician's valuable time; omit details of their history which they deem unimportant; be embarrassed to mention things they think will place them in an unfavorable light; not understand medical terminology; or believe the physician has not really listened and, therefore, does not have the information needed to make good treatment decisions.
Several approaches can be used to facilitate open communication with a patient. Physicians should:
- sit down
- attend to patient comfort
- establish eye contact
- listen without interrupting
- show attention with nonverbal cues, such as nodding
- allow silences while patients search for words
- acknowledge and legitimize feelings
- explain and reassure during examinations
- ask explicitly if there are other areas of concern
What happens when physicians and patients disagree?
One third to one half of patients will fail to follow a physician's treatment recommendations. Labeling such patients "noncompliant" implicitly supports an attitude of paternalism, in which the physician knows best (see: Difficult Patient Encounters). Patients filter physician instructions through their existing belief system and competing demands; they decide whether the recommended actions are possible or desirable in the context of their everyday lives.
Compliance can be improved by using shared decision making. For example, physicians can say, "I know it will be hard to stay in bed for the remainder of your pregnancy. Let's talk about what problems it will create and try to solve them together." Or, "I can give you a medication to help with your symptoms, but I also suspect the symptoms will go away if you wait a little longer. Would you prefer to try the medication, or to wait?" Or, "I understand that you are not ready to consider counseling yet. Would you be willing to take this information and find out when the next support group meets?" Or, "Sometimes it's difficult to take medications, even though you know they are important. What will make it easier for you to take this medication?"
Competent patients have a right to refuse medical intervention. Dilemmas may arise when a patient refuses medical intervention but does not withdraw from the role of being a patient. For instance, an intrapartum patient, with a complete placenta previa, who refuses to undergo a cesarean delivery, often does not present the option for the physician to withdraw from participation in her care (see: Maternal-Fetal Conflict). In most cases, choices of competent patients must be respected when the patient cannot be persuaded to change them.
What can a physician do with a particularly frustrating patient?
Physicians will sometimes encounter a patient whose needs, or demands, strain the therapeutic alliance. Many times, an honest discussion with the patient about the boundaries of the relationship will resolve such misunderstandings. The physician can initiate a discussion by saying, "I see that you have a long list of health concerns. Unfortunately, our appointment today is only for fifteen minutes. Let's discuss your most urgent problem today and reschedule you for a longer appointment. That way, we can be sure to address everything on your list." Or, "I know that it has been hard to schedule this appointment with me, but using abusive language with the staff is not acceptable. What do you think we could do to meet everybody's needs?"
There may be occasions when no agreeable compromise can be reached between the physician and the patient. And yet, physicians may not abandon patients. When the physician-patient relationship must be severed, the physician is obliged to provide the patient with resources to locate ongoing medical care.
When is it appropriate for a physician to recommend a specific course of action or override patient preferences?
Under certain conditions, a physician should strongly encourage specific actions. When there is a high likelihood of harm without therapy, and treatment carries little risk, the physician should attempt, without coercion or manipulation, to persuade the patient of the harmful nature of choosing to avoid treatment.
Court orders may be invoked to override a patient's preferences. However, such disregard for the patient's right to noninterference is rarely indicated. Court orders may have a role in the case of a minor; during pregnancy; if harm is threatened towards oneself or others; in the context of cognitive or psychological impairment; or when the patient is a sole surviving parent of dependent children. However, the use of such compulsory powers is inherently time-limited, and often alienates the patient, making him less likely to comply once he is no longer subject to the sanctions.
What is the role of confidentiality?
Confidentiality provides the foundation for the physician-patient relationship. In order to make accurate diagnoses and provide optimal treatment recommendations, the physician must have relevant information about the patient's illness or injury. This may require the discussion of sensitive information, which would be embarrassing or harmful if it were known to other persons. The promise of confidentiality permits the patient to trust that information revealed to the physician will not be further disseminated. The expectation of confidentiality derives from the public oath which the physician has taken, and from the accepted code of professional ethics. The physician's duty to maintain confidentiality extends from respect for the patient's autonomy.
Would a physician ever be justified in breaking a law requiring mandatory reporting?
In general, mandatory reporting requirements supersede the obligation to protect confidentiality. While the physician has a moral obligation to obey the law, she must balance this against her responsibility to the patient. Reporting should be done in a manner that minimizes invasion of privacy, and with notification to the patient. If these conditions cannot be met, or present an intolerable burden to the patient, the physician may benefit from the counsel of peers or legal advisors in determining how best to proceed. (For a discussion on the limits of confidentiality, see the topic page on Confidentiality.)
What happens when the physician has a relationship with multiple members of a family?
Physicians with relationships with multiple family members must honor each individual's confidentiality. Difficult issues, such as domestic violence, sometimes challenge physicians to maintain impartiality. In many instances, physicians can help conflicted families towards healing. At times, physicians work with individual family members; other times, they may serve as a facilitator for a larger group. As always, when a risk for imminent harm is identified, the physician must break confidentiality.
Physicians can be proactive about addressing the needs of changing family relationships. For example, a physician might tell a preteen and her family, "Soon you'll be a teenager. Sometimes teens have questions they would like to discuss with me. If that happens to you, it's okay to tell your parents that you'd like an appointment. You and I won't have to tell your parents what we talk about if you don't want to, but sometimes I might encourage you to talk things over with them."
The physician-family relationship also holds considerable healing power. The potential exists to pursue options that can improve the quality of life and health for the entire family.
Top | Additional Readings | Related Websites
Case studies:Case 1 | Case 2
Related discussion topics:Confidentiality, Difficult Patient Encounters, Informed Consent,Maternal-Fetal Conflict, Professionalism, Student Issues
Core clerkship material for:Family Medicine | Orthopedics | Otolaryngology | Surgery | Urology
MaryJo Ludwig, MD
Clinical Faculty, Department of Family Medicine
Resident Faculty, Valley Medical Center, Renton
Wylie Burke, MD, PhD
Facutly, Bioethics & Humanities
Doctor-patient (or client-professional, practitioner-patient, lay-professional) communication has been the focus of scholarly study and public concern for several decades. Within medicine, communication is increasingly seen as a critical skill set in the delivery of care. The doctor-patient relationship is a special kind of relationship; while patients may not know their doctors in a personal sense (and often, vice versa) they are nonetheless asked to disclose intimate details of their personal lives and reveal their bodies for examination. This vulnerability is not reciprocated from doctors to patients. There is, therefore, a degree of social imbalance in this relationship (albeit one that is socially sanctioned), which may have a bearing on communication. Barriers to effective communication between doctors and their patients, including such factors as class, gender, race, and health literacy, are discussed.
Keywords: Cultural Competence; Communication; Functionalism; Health Care Disparities; Medical Encounter; Patient Centered Care; Role Format; Sick Role
Doctor-patient (or client-professional, practitioner-patient, lay-professional) communication has been the focus of scholarly study and public concern for several decades. Within the medical field, communication is increasingly seen as a critical skill set in the delivery of care. The doctor-patient relationship is a special kind of relationship; while patients may not know their doctors in a personal sense (and often, vice versa) they are nonetheless asked to disclose often intimate details of their personal lives and reveal parts of their bodies for examination. This vulnerability is not reciprocated from doctors to patients. There is, therefore, a degree of social imbalance in this relationship (albeit one that is socially sanctioned). This may have a bearing on communication; that is, the full range of spoken, facial, bodily, and symbolic expressions that people use when they interact and exchange information with each other.
Classic studies in sociology have highlighted the potential for conflict in doctor-patient communication and identified how assumptions about patients based on class, gender, age and race influence the content and tone of communication. Moreover, research has shown that patients who understand their doctors are more likely to acknowledge their health problems, understand their treatment options, modify their health-related behaviors at their doctor’s recommendation, and adhere to treatment recommendations. Given this compelling evidence, two-thirds of medical schools now provide their students with instruction on how to communicate with patients and how to develop interpersonal skills to support effective communication (Travaline et al., 2005). Such skills, which include listening, explaining, questioning, counseling and motivating patients, are becoming core competencies for medical practice, and in the United States, demonstration of such skills is required for licensure and board certification. Nonetheless, there continue to be many barriers to effective communication between doctors and their patients, including such factors as gender, race, and health literacy.
Physician-patient communication has been central to scholarly research for at least fifty years and the ideal medical encounter (for which effective communication is critical) is increasingly viewed as one that is patient-centered (Mead & Bower, 2000) from obtaining the patient's medical history to conveying a treatment plan. The medical or clinical encounter entails much information sharing about symptoms, diagnosis, and treatment options in what has been historically and is increasingly recognized as a therapeutic relationship that provides the first step toward healing (Travaline, Ruchinskas & D'Alonzo, 2005). However, studies of patient-doctor communication demonstrate that communication is rarely patient-centered and is in fact influenced by many characteristics and ideas.
There is a surprising degree of regularity and ritual associated with communication between doctors and patients, or, more correctly, with the medical encounter. In a classic study of outpatient clinic visits in Scotland, Phil Strong (1979) found that there is an unspoken set of rules and rituals that guide the medical encounter or consultation. These rituals, encoded as role formats (or as sociologist Erving Goffman might put it, social scripts), provide tacit resources that both patients and doctors call upon, depending on their assessment of the encounter (that is, what kind of consultation they consider it to be). Strong identifies four such formats:
- Bureaucratic (doctor and patient are both polite and avoid conflict, though doctors assume patients to be less than competent);
- Charity (doctors draw attention to patients' incompetence);
- Clinical (in which the doctor and patient tacitly agree on the doctor's expertise and authority); and
- Private (in which the doctor focuses on "selling" his competence).
Core to these formats is the way the doctor typically asserts control over the communication process and directs the conversation by the following tactics: interrupting patients or breaking off conversation; excluding the patient by writing while they tell their story; and eliciting information from patients but not explaining why such information was required. Strong (1979) notes that such tactics cement the asymmetry between doctor and patient, and subsequent studies in social psychology have confirmed their use.
Indeed, studies of doctor-patient communication often begin with the observation that the relationship between doctors and their patients is unequal in terms of power, status, and knowledge. For instance, in Talcott Parsons's (1951) discussion of the sick role (a socially deviant state) the patient is entitled to be sick, provided she or he assumes certain obligations, such as making an effort to get well. Accordingly, doctors are obliged to help patients get well. How they interact and communicate with each other is central to how the sick role is negotiated, since doctors occupy a position of authority in relation to the patient (Nettleton, 1992). While such asymmetry is unproblematic in a functionalist view of the social world, it ignores the potential for conflict between doctor and patient, or of the potential for value judgments to influence the process of making clinical decisions.
For instance, doctors may discount information that patients provide and be dismissive toward them. In studies of how patients use emergency rooms, researchers have found that doctors are often dismissive of patients because in their view, based on the symptoms that patients describe, some patients should not be in the emergency room in the first place. That is, patients are judged as being overanxious (especially mothers of young children, see Roberts, 1992) or, in certain situations (such as patients who are injured but who have also been drinking alcohol) may be judged for behaving in ways that are seen as irresponsible. In such cases, patients may be judged as "normal rubbish" (Jeffery, 1979); that is, they are seen as presenting with symptoms that are considered inappropriate or trivial. While doctors usually do not explicitly inform patients of what they are thinking or what their value judgments are, they may communicate disapproval nonverbally by not listening to patients or not demonstrating empathy. More recent research confirms that in situations characterized by prejudice and fear, such as in the case of consultations about HIV risk, doctors may handle communication ineffectively in ways that make patients feel uncomfortable or even stigmatized (Epstein et al., 1998).
Barriers to Doctor-Patient Communication
Social characteristics such as gender and race influence the content and tone of doctor-patient communication, and many studies have demonstrated how the social backgrounds of both patients and doctors create barriers to effective communication. Many studies have found social class, gender, and racial differences in physician communication style, that is, how physicians talk with patients and communicate nonverbally.
First, social class differences are significant in determining how doctors communicate with their patients. Although there have been some changes in medical school recruitment, medicine is largely practiced by members of the middle, upper-middle, or upper class and as such, reflects values associated economic independence and autonomy (Mechanic, 1974). These values influence communication style, especially in terms of the language and the forms of expression used by doctors. For instance, members of the middle class tend to be more verbally explicit, while working class members tend to rely more on nonverbal communication. This means, in doctor-patient encounters between middle-class physicians and working-class patients, physicians may be more likely to talk than their patients (Cooper & Roter, 2003). In addition, patients whose health literacy levels are low (that is, they have difficulties reading and understanding written medical information), which is often associated with social class, are more likely to report poor communication with doctors in face-to-face encounters (Schillinger et al., 2004).
Second, there are differences between male and female physicians in the way they interact with their patients in general (Brody & Hall, 2000). Male physicians have been found to engage less in nonverbal gestures that communicate warmth and empathy, such as smiling, eye contact, nodding, hand gesturing, direct body orientation (facing the patient), and "back-channel responses" (such as saying "mm-hmm" to acknowledge what the patient is saying) (Cooper & Roter, 2003). Similarly, observation...