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Treating the Patient

Posted By Grace Wilson, Tuesday, May 28, 2013

"The good physician treats the disease.  The great physician treats the patient who has the disease.”

William Osler, 1849-1919

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Rachel is scared.  At 55 years old, she’s faced a lot in her life, and has managed pretty well to this point.  She worked in a local factory until she was laid off 5 years ago.  Although she’s been struggling financially since then, she figures that leaving the physically demanding job has probably been better for her health, and she and her husband Daniel manage to get by on his monthly disability check.  With the help of her physician, Dr. Andrews, her Type II Diabetes has been mostly well controlled since her diagnosis 15 years ago.  Now, though, a bigger medical problem looms on the horizon – she found a lump in her breast last week.  Rachel is very familiar with the realities of what this could mean, because her mother died of breast cancer when she was Rachel’s age.  Daniel is a big emotional support for her, but he doesn’t have much knowledge of medical issues, and she is afraid to burden him with her fears because he is struggling with his own health concerns.  Now, Rachel and Daniel are sitting in an exam room waiting for Dr. Andrews to come in to discuss the results of Rachel’s mammogram and consider what her options for further diagnosis and treatment will be.

Dr. Andrews has treated Daniel and Rachel for over 20 years.  He is familiar with Rachel’s medical history, her family situation, and her fondness for baking pies every Christmas to share with the office.  Now, he has the results of her mammogram.  Although she’s going to need a biopsy to confirm the presence of cancer, the film is not looking good.   As he walks into the room, he sees the mix of hope and fear on Rachel and Daniel’s faces, and he knows that the relationship he has with them will be an important part of her quality of life – both medically and personally – in the days to come.

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What can be done to foster a positive provider-patient relationship?
The provider-patient relationship can be a rich source of support and healing for patients who are facing stress related to health and illness.  It is built on trust, knowledge, and, increasingly, collaboration.  In the IOM 2001 report "Crossing the Quality Chasm,” six aims for healthcare are presented – among them, patient-centered care, which emphasizes the relationship between patient and provider.  The authors posit that the best healthcare is based on a continuous, healing relationship that is customized on patient needs and values, with safety, transparency, and the free flow of ideas. 

Research has shown that attention to the provider-patient relationship is beneficial for both parties.  Patients with chronic disease have improved quality of life, functional, and emotional status when doctor-patient communication is functioning well (Theofilou, 2011).  Patients who have limited agency and are unable to speak for themselves may be given a voice through a healthy relationship with a provider who cares (Shannon, 2009).  In turn, providers who spend time reflecting on provider-patient relationships tend to have lower stress and increased levels of empathy (Battegay et al., 1991).  Both Rachel and Dr. Andrews benefit from his attention to their relationship.

What can be done to foster a positive provider-patient relationship?  One of the keys is maintaining a patient-centered outlook with good communication (Fong Ha & Longnecker, 2010).   Collaborative communication, which integrates the patient’s perspectives and input, and conflict resolution are particularly important.  Patients report that the extent to which they feel their provider is listening to them is also a key determinant of relationship quality (Jagosh, Boudreau, Steinert, MacDonald, & Ingram, 2011).  In other words, if Rachel feels that Dr. Andrews is really listening to her, and actively communicating with her to increase her sense of agency surrounding her care, she will feel cared for and experience the benefits of a strong doctor-patient relationship.

How can you determine how the provider-patient relationship is going?  First, do a self-check.  To what extent do you feel like you understand your patients as "a whole person” rather than a diagnosis or a disease?  How often are you using active listening skills, such as reflective statements and clarifying questions?  What does your gut tell you about the relationships you maintain with your patients?  All of these questions are important – remember that relationships are always a reciprocal two-way street.  The way you feel about your relationship with your patients can tell you a lot about the state they are in.  More formal assessments are also available.  In 2012, a systematic review of 19 instruments assessing the doctor-patient relationship was published (Eveleigh et al., 2012).  Appendix 2 in the article provides a concise table summarizing the characteristics of the different measures.  While many of these measures are primarily utilized for research purposes, providers may find clinical utility in a more formalized assessment of the provider-patient relationship.
How can you determine how the provider-patient relationship is going?  

Most – if not all – providers would agree that maintaining effective communication with their patients is important, but even when the desire is there, barriers still exist to making this relationship a primary focus of treatment.  First, the pressure to see more patients in a shorter amount of time, coupled with patients’ increasingly complex presentations, can leave providers wondering how they could possibly fit more into their already packed encounters.  Second, opening oneself up to patients’ physical, emotional, and spiritual pain requires vulnerability on the part of the provider and risk of personal hurt or burnout. 

A few suggestions can help with these concerns:

• Simple strategies like making eye contact with patients and repeating patients’ words back to them can help with feelings of connection without increased time on the providers’ part.

 At a policy level, alternative payment structures should be explored to address the broader system issue of providers’ time.  

 To help with the potential burden of vulnerability, providers should engage in self-care and build strong professional and personal support systems from whom they may draw strength.  

 Providers who work in collaborative health care are uniquely posed to strengthen patient care while simultaneously diffusing the personal burden to be "all things to all people.”  Share the care!! 

References:

Battegay, M., Weber, R., Willi, J., Eich, D., Siegenthaler, W., & Luthy, R. (1991). Exploring the doctor-patient relationship reduces staff stress and enhances empathy when caring for AIDS patients. Psychotherapy & Psychosomatics, 56(3), 167-173.  doi: 10.1159/000288551

Eveleigh, R.M., Muskens, E., van Ravesteijn, H., van Dijk, I., van Rijswijk, E., & Lucassen, P. (2012). An overview of 19 instruments assessing the doctor-patient relationship: Different models or concepts are used. Journal of Clinical Epidemiology, 65, 10-15.  doi:10.1016/j.jclinepi.2011.05.011

Fong Ha, J., & Longnecker, N. (2010) Doctor-patient communication: A review. The Ochsner Journal, 10, 38-43.

Jagosh, J., Boudreau, J.D., Steinert, Y., MacDonald, M.E., & Ingram, L. (2011).  The importance of physican listening from the patients’ perspective: Enhancing diagnosis, healing, and the doctor-patient relationship. Patient Education and Counseling, 85, 369-374. doi:10.1016/j.pec.2011.01.028

Theofilou, P. (2011). Improved quality of life, functional and emotional status: The doctor patient relationship. Primary Health Care: Open Access, 1(1). Accessed online.  doi:10.4172/phcoa.1000e101


Grace Wilson is a PhD candidate at East Carolina University in Greenville, NC.  She currently works as a behavioral health provider at a rural FQHC, and she will begin her doctoral internship in Oklahoma in August.  Her research is on couples, the childbearing experience, and the doctor-patient relationship.

Tags:  provider patient relationship 

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Comments on this post...

Teresa Rogers says...
Posted Thursday, June 27, 2013
With response to how is the provider- patient relationship going, I agree, doing a self-check is a vital first step. We can get caught up in long days and many many clients and occasionally the question of "how is my relationship with the patient going?" gets lost. Doing a self-check before and after the session would be beneficial for all. Further, asking the patient about the relationship may be effictive and increase the patient's agency and be a great modeling tool.

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