"The good physician treats the disease.
The great physician treats the patient who has the disease.”
William Osler, 1849-1919
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.
|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!!
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,
(2011). Improved quality of life, functional and emotional status: The doctor
patient relationship. Primary Health
Care: Open Access, 1(1). Accessed
|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.|