The patient–doctor relationship is central to medicine. This relationship has two fundamental components (Calman and McLean, Reference Calman and McLean1984). The first is the doctor's care, skill and knowledge; the second is information-giving to help the individual make decisions. Hence, communication and trust are essential in this relationship.
The problem arises when doctors see patients as sick people from whom to extract information or to whom to impart advice, and they therefore ignore a vital purpose of communication, which is to initiate and enhance the relationship with their patients (Persaud, Reference Persaud2005). Long and Jiwa (Reference Long and Jiwa2004) found that in 25% of medical consultations, the chief concerns of patients had not been elicited and 40% of cancer specialists in the study by Fallowfield et al. (Reference Fallowfield, Jenkins, Farewell, Saul, Duffy and Eves2002) were found to agree that patients preferred not to know too much about their condition, even if the patients said otherwise.
Because this is such an important issue we have interviewed all the psychiatric specialist registrars in Wales (U.K.) to establish their attitudes and expectations about the cultural factors in the doctor–patient relationship.
Patients expect their doctors to be professional in attitude, to provide expert opinion and knowledge about their diagnosis and management; to be listened to and, finally, to come to an agreed plan of how best to manage their problem jointly. Doctors think they can understand human nature and work with individuals to empower them to manage their own illness as much as possible. This may produce a culture change in help-seeking behavior and views of psychiatric illness in general.
Families can provide care and support, or, in some cases, abuse the family members they are supposed to be caring for. They may influence the course of the illness indirectly or directly in complex cases where family dynamics are playing a role in illness. The contribution of the families into the care of their relatives varies depending on the individual family members and patient involved. Families can be warm, supportive, critical, or protective of the patient. In general, family members don't usually tend to interfere with the patient–doctor relationship except in those circumstances where the family dynamics also contribute to the patient's illness. Generally, the clinician's priority is the patient and his or her well-being, and the relationship with the patient has seldom been undermined by the family's influence. Nevertheless, in some cases clinicians have faced relatives who have attempted to draw them into a situation which could damage their relationship with the patients.
At times, what the patient wants may be at odds with the doctor's priorities in terms of management or treatment; for example, the patient may want an alternative therapy such as acupuncture while the doctor's preferred line of management is pharmacotherapy. The doctors’ views are that such alternative treatments are the patient's choice and the doctor's role is to discuss evidence for its effectiveness (or lack of it) compared to prescribed medication or psychotherapy and to make sure it does not interact with prescribed medications. Clinicians agree that the groups of clients using alternative therapies are usually less ill and more psychologically minded.
Most patients see their doctors as professionals without their ethnicity or gender impinging on the doctor–patient relationship. The doctors in our study generally agreed that cultural differences make the job interesting and that conflicts in the relationship generally arise through misunderstandings. Today patients have far more control over and knowledge about their rights and their illness, which, to some extent, has improved the doctor–patient relationship and allows an agreed management plan to be made and implemented. Clinicians do not think that complaints about medications are a cultural issue, rather they have more to do with education and the ability to follow the logic of medical explanation. The patient has the right to make a choice and the clinician's role is to inform them so they can make an informed choice. It was also found that those with a better education tended to be more challenging and less compliant.
In the course of evaluating and caring for patients, there are occasions when doctors feel “stuck” in not knowing how to respond to certain comments that arise during the interview. The difficulties may result from misunderstandings between patient and doctor or from comments that reflect unstated issues. In both cases, mutual dissatisfaction ensues when these underlying factors are not properly addressed. Furthermore, particularly if feeling uncertain of the reasons for these difficulties or if dissatisfied with the conduct of the interview, doctors may respond in an authoritative manner, which diminishes the patient's ability to participate actively in the interaction. There are many reasons why communicating with patients is stressful for doctors, including the fact that it often occurs under very constrained circumstances that are usually far from ideal in terms of setting and time. Also, sick people are not usually able to converse as easily as when they are well, and are often hampered by strong emotions, like fear of a particular diagnosis or procedure. The research evidence indicates that the responsibility for good interaction between parties tends to be seen by patients as lying much more heavily on doctors’ shoulders than in most dialogues. The continuing advance of science in medicine also means that doctors have to make more effort to communicate in lay terms in order to educate their patients about the advances in medicine. This confirms that communication lies at the heart of the doctor–patient relationship. Good communication is the key to making a correct diagnosis and formulating a good treatment plan. A patient-oriented style of communication, an ability to explore and discuss patients’ expectations and behaviour, a warm and friendly approach, and an ability to gain the trust of the patient through the provision of well-structured and specific information are attributes that have been found to be effective in influencing patients’ behavior (Persaud, Reference Persaud2005). The patient has the right to be fully informed in order to be able to make an informed decision on all treatment options. Perhaps partnership with the patient is the most important factor in changing health-related behavior. Finally, from the training perspective, it is important to discuss the patient–doctor relationship with all our trainees under supervision.
