The doctor-patient relationship is central to the practice of medicine and is essential for the delivery of high-quality health care in the diagnosis and treatment of disease. The doctor-patient relationship forms one of the foundations of contemporary medical ethics. Most medical schools and universities teach medical students from the beginning, even before they set foot in hospitals, to maintain a professional rapport with patients, uphold patients' dignity, and respect their privacy.

[edit] Importance

A patient must have confidence in the competence of their doctor and must feel that they can confide in him or her. For most physicians, the establishment of good rapport with a patient is important. Some medical specialties, such as psychiatry and family medicine, emphasize the doctor-patient relationship more than others, such as pathology or radiology.

The quality of the patient-physician relationship is important to both parties. The better the relationship in terms of mutual respect, knowledge, trust, shared values and perspectives about disease and life, and time available, the better will be the amount and quality of information about the patient's disease transferred in both directions, enhancing accuracy of diagnosis and increasing the patient's knowledge about the disease. Where such a relationship is poor the physician's ability to make a full assessment is compromised and the patient is more likely to distrust the diagnosis and proposed treatment, causing decreased compliance to actually follow the medical advice. In these circumstances and also in cases where there is genuine divergence of medical opinions, a second opinion from another physician may be sought or the patient may choose to go to another doctor.

[edit] Issues

[edit] Physician superiority

The physician may be viewed as superior to the patient, because the physician has the knowledge and credentials, and is most often the one that is on home ground.

The doctor-patient relationship is also complicated by the patient's suffering (patient derives from the Latin patior, "suffer") and limited ability to relieve it on his/her own, potentially resulting in a state of desperation and dependency on the physician.

A physician should at least be aware of these disparities in order to establish rapport and optimize communication with the patient.

[edit] Benefiting or pleasing

A dilemma may arise in situations where what is the most efficient treatment (or avoidance of treatment) is not the same as what the patient wants for various reasons. In such cases, the physician may need to choose between the patient's physical health or other rather material benefits on one hand and the doctor-patient relationship or other psychological or emotional aspect on the other.

[edit] Formal or casual

There may be differences in opinion between the doctor and patient in how formal or casual the doctor-patient relationship should be.

For instance, according to a Scottish study,^[1] patients want to be addressed by their first name more often than is currently the case. In this study, most of the patients either liked (223) or did not mind (175) being called by their first names. Only 77 disliked it, most of whom were aged over 65.^[1] On the other hand, most patients don't want to call the doctor by his or her first name.^[1]

[edit] Perspectives

The physician-patient relationship can be analyzed from the perspective of ethical concerns, in terms of how well the goals of non-maleficence, beneficence, autonomy, and justice are achieved. Many other values and ethical issues can be added to these. In different societies, periods, and cultures, different values may be assigned different priorities. For example, in the last 30 years medical care in the Western World has increasingly emphasized patient autonomy in decision making.

The relationship and process can also be analyzed in terms of social power relationships (e.g., by Michel Foucault), or economic transactions. Physicians have been accorded gradually higher status and respect over the last century, and they have been entrusted with control of access to prescription medicines as a public health measure. This represents a concentration of power and carries both advantages and disadvantages to particular kinds of patients with particular kinds of conditions. A further twist has occurred in the last 25 years as costs of medical care have risen, and a third party (an insurance company or government agency) now often insists upon a share of decision-making power for a variety of reasons, reducing freedom of choice of healthcare providers and patients in many ways.

In some settings, e.g. the hospital ward, the patient-physician relationship is much more complex, and many other people are involved when somebody is ill: relatives, neighbors, rescue specialists, nurses, technical personnel, social workers and others.

[edit] Other Perspectives

In non-Western societies, particularly traditional Eastern societies and American Indian societies, the physician/patient relationship may be couched in different terms. The illness may be seen as a violation of the spiritual realm and the cure will be seen likewise as having to take place in the spiritual realm. Violation of some spiritual rule can result in illness; persons distant to the patient may have caused illness by manoeuvres in the spiritual realm, by cursing or causing another practitioner / shaman / healer to place the curse. Powerful faith in these factors can result in serious illness or cure. Spirits can be part of a culture's usual pantheon, ancestor spirits or arbitrary new spirit forces arising independently or as derived from an existing object in the real world: such as an animist spirit coming from a totem animal, mountain or other thing. As in the scientific West, the practitioner is assumed to have special knowledge or power, and is paid by the patient in some form.

[edit] Bedside manner

Bedside manner is essential in affecting the doctor-patient relationship. A good bedside manner is typically one that reassures and comforts the patient while remaining honest about a diagnosis. Vocal tones, body language, openness, presence, and concealment of attitude may all affect bedside manner. Poor bedside manner leaves the patient feeling unsatisfied, worried, frightened, or alone. Bedside manner becomes difficult when a healthcare professional explains to the patient the true diagnosis, while keeping the patient from being alarmed.

[edit] Examples in fiction

• Dr. Gregory House (of the show House) has a caustic, callous bedside manner. However, this is an extension of his normal personality.
• In Grey's Anatomy, Dr. Burke compliments Dr. George O'Malley's ability to care for Dr. Bailey's baby by saying "it speaks to a good bedside manner."
• Doc Martin from the Doc Martin British TV series is a good example of a doctor with a poor bedside manner.
• In Lost, Hurley tells Jack Shephard that his bedside manner "sucks". Later in the episode, Jack is told by his father to put more hope into his sayings, which he does when operating on his future wife.
• In Closer, Larry, the doctor tells Anna when they first meet that he is famed for his bedside manner.
• In Scrubs, J.D is a good example of a doctor with great bedside manner, while Elliot Reid is a doctor with poor or non-existent bedside manner. Dr. Cox is an interesting subversion, in that his manner is gruff and intense while still inspiring patients to do their own best to aid in the healing process, akin to a drill sergeant. It is also remarked on this show that the most amount of time that a doctor needs to be in the presence of the patient before he finds out everything he needs to know is 18 seconds approx.
• In Star Trek: Voyager, the Doctor often compliments himself on the charming bedside manner he developed with the help of Kes.
• In M*A*S*H, Hawkeye Pierce, Trapper John McIntyre, B.J. Hunnicutt, and Sherman Potter all possess a caring and humorous bedside manner meant to help patients cope with traumatic injuries. Charles Winchester initially possesses no real bedside manner, acting with detached professionalism, until the rigors of his job help him develop a sense of compassion for his patients. Frank Burns has a poor bedside manner, constantly minimizing the seriousness of his patients' injuries, accusing them of cowardice and goading them to return to the front lines.

[edit] See also

• Physician
• Medical ethics

[edit] References

1. ^ ^{a b c} McKinstry B (October 1990). "Should general practitioners call patients by their first names?". BMJ 301 (6755): 795'6. doi:10.1136/bmj.301.6755.795. PMID 2224269. 

[edit] Further information

• Alexander GC, Casalino LP, Meltzer DO (August 2003). "Patient-physician communication about out-of-pocket costs". JAMA 290 (7): 953'8. doi:10.1001/jama.290.7.953. PMID 12928475. 
• Alexander GC, Casalino LP, Tseng CW, McFadden D, Meltzer DO (August 2004). "Barriers to patient-physician communication about out-of-pocket costs". J Gen Intern Med 19 (8): 856'60. doi:10.1111/j.1525-1497.2004.30249.x. PMID 15242471. 
• Alexander GC, Casalino LP, Meltzer DO (March 2005). "Physician strategies to reduce patients' out-of-pocket prescription costs". Arch. Intern. Med. 165 (6): 633'6. doi:10.1001/archinte.165.6.633. PMID 15795338. 
• Alexander GC, Lantos JD (2006). "The doctor-patient relationship in the post-managed care era". Am J Bioeth 6 (1): 29'32. doi:10.1080/15265160500394556. PMID 16423784. 
• Pham HH, Alexander GC, O'Malley AS (April 2007). "Physician consideration of patients' out-of-pocket costs in making common clinical decisions". Arch. Intern. Med. 167 (7): 663'8. doi:10.1001/archinte.167.7.663. PMID 17420424. 

[edit] External links

Look up bedside manner in Wiktionary, the free dictionary.

• Report of a large summit of patients and physicians, where the ideal patient-physician relationship in the 21st century was discussed. Organised by Johns Hopkins and American Healthways in 2003
• Time Magazine article: "When the patient is a Googler" - Mary Shomons response I II - Trisha Torreys response