Characteristics of the doctor-patient relationship. Models of doctor-patient relationship

• The doctor and the patient meet in the therapeutic situation, which has five elements: the problem, the therapist, the patient, the psychological climate and the therapeutic activity.
• The doctor-patient (therapeutic) relationship is a working partnership towards health-related goals. It differs from a social or intimate relationship: the doctor takes responsibility for conducting it, it is unreciprocal, it has a specific purpose, the focus is on the patient, it ends when the goal is met, and it is entered through necessity.
• The quality of the relationship matters to both sides. A good one improves information, diagnosis and treatment; a poor one reduces trust and compliance.
• Patients want to be treated as individuals, not numbers. The "ideal" doctor is empathetic, humane, personal, frank, respectful and thorough.
• The relationship is shaped by the personal motives of doctor and patient, above all power motivation.
• Models: the disease centred model (doctor decides) against the patient centred model (shared decisions). The patterns of the relationship depend on how much control each side has: paternalism (doctor high, patient low), consumerism (doctor low, patient high), default (both low, an impasse) and mutuality or partnership (both high).
• The relationship is also a process with a content level and a process level, with transference and countertransference, defence mechanisms in illness (denial, regression, affective isolation, accusing) and resistance.

Doctors and patients meet in the therapeutic situation. The seminar slide shows it as a set of overlapping circles, each one a feature of the meeting: professional situation with goal-directed activities; stable role behaviours (the role of the doctor and the role of the patient); time and place; the therapeutic alliance; the therapeutic doctor-patient relationship; unreciprocity of the relationship; and therapeutic communication.

The lecture on the therapeutic situation names five elements of it, drawn as a cycle of linked ovals: the problem, the therapist, the patient, the psychological climate and the therapeutic activity.

The lecture is organised as seven points: elements of the therapeutic situation, characteristics of the therapeutic situation, basic needs of the patients, the role of the doctor, personal characteristics of the doctor and the patient, therapeutic alliance and therapeutic adherence. The seminar on the doctor-patient relationship covers its definition, the value of a positive relationship, important characteristics of a good relationship, types of powers in therapy, models of the relationship, disease centred versus patient centred model, factors related to the establishing of trust, skills to enhance the relationship and the relationship as a process.

The doctor-patient relationship is a relationship in which the doctor and the patient work together towards the therapeutic goals and the task of assisting the patient to regain the inner resources and to facilitate health. It differs in many ways from a social or intimate relationship, because it focuses on the patient: their needs, experiences, feelings and expectations (the lecture says "needs, experiences, feelings and ideas of the patient only").

The slide shows the two partners with the qualities each brings. The patient brings insight, honesty, persistence and motivation to change. The therapist brings empathy, genuineness, confidentiality and unconditional positive regard. Between them runs the therapeutic relationship, built on rapport and trust.

Characteristics of the therapeutic relationship

• Doctors take responsibility for conducting the relationship.
• Unreciprocity of the relationship: it is not a relationship for mutual gain, and the doctor expects nothing similar in return.
• The relationship has a specific purpose and health-related goals.
• The focus is on the patient.
• The relationship terminates when the identified goal is met (a temporary alliance).
• The relationship is entered through necessity.

The same relationship is a professional situation with stable roles, responsibility, strict ethical boundaries, goal-orientated activities and an imbalance of power. Trust, rapport and collaboration are important characteristics, and a therapeutic relationship should never involve sexual contact, abuse or prejudice.

Rules, roles and one-way process

The rules that apply in a doctor-patient relationship are different from those that govern other social relations. The interaction is shaped by the differing social roles and the different needs of doctor and patient. The relationship is a one-way process: it would be highly inappropriate if the doctor started to discuss her own problems, or if the patient asked her personal questions.

Two kinds of doctor's behaviour are distinguished.

Why the quality of the relationship matters

The quality of the patient-physician relationship is important to both parties. A patient must have confidence in the competence of their doctor and must feel that they can confide in him or her.

The better the relationship in terms of mutual respect, knowledge, trust, shared values and time available:

• the better the amount and quality of information about the patient's disease transferred in both directions;
• the better the accuracy of diagnosis and treatment.

In a poor relationship the physician's ability to make a full assessment is compromised, the patient is more likely to distrust the diagnosis and treatment, and compliance with the medical advice decreases.

Basic needs of the patients

Good patient care consists of responding to the patients' medical and psychological needs: listening to, understanding and responding to them. The key psychological need on the slide is that patients want to be treated as individuals, not numbers.

A slide on patients' complaints lists the "top 5 gripes": unclear explanations, slow test results, billing disputes, getting an appointment when sick, and rushed office visits.

The "Basic needs of the patients" slide shows a patient with an arm in a sling surrounded by speech bubbles that show what happens when the needs are not met: "The doctor didn't listen", "I felt rushed and was annoyed by that", "He/she wouldn't talk openly", "I felt deserted", "I never received explanations", "He/she is hiding something" and "I was ignored".

Mismatch of expectations and experiences

Patients' expectations and what some of them actually get do not match:

Portrait of the "ideal" doctor from the patient's perspective

• Empatheticthe doctor tries to understand what I am feeling and communicates that understanding to me.
• Humanethe doctor is caring, compassionate and kind.
• Personalthe doctor is interested in me, interacts with me and remembers me as an individual.
• Frankthe doctor tells me what I need to know in plain language.
• Respectfulthe doctor takes my input seriously and works with me.
• Thoroughthe doctor is conscientious and persistent.

The slide illustrates the opposite with a cartoon of a doctor leaning over a patient who is pushed back in his chair, saying "Which part of what I'm saying don't you understand?".

The role of the doctor

The role of the doctor in the therapeutic situation has five parts:

• motivation;
• professional (medical) skills and knowledge;
• psychological competence, meaning psychological skills and knowledge;
• attention to the relationship;
• self-reflection.

The slide shows a doctor scratching his head with an angel on one shoulder and a devil on the other, a picture of the self-reflection and inner conflict the role calls for.

The personal characteristics of doctor and patient influence the process and outcome of the therapeutic relationship. Two types are particularly important: the motives and the self-image of the doctor and the patient. At least three motives seem necessary for understanding the dynamics of the relationship: power motivation, affiliation motivation and achievement motivation. These motives determine how the doctor and the patient orient themselves to one another and to their task.

Power motivation determines how much doctor and patient will be concerned with influencing and controlling one another.

• By asking for help, patients place themselves in a dependent position, where they often feel weaker and more vulnerable.
• The doctor must deal with the tendency to feel superior: the satisfactions of power and control may overshadow the goal of acting in the patient's best interest.
• If doctor and patient are unable to resolve power struggles, the relationship can degenerate into rebellion and passivity by the patient or rejection by the doctor.

This is why the seminar lists "types of powers in therapy" and why the patterns of the relationship in the next section are described by how much control each side holds. An imbalance of power is also a characteristic of the relationship.

The doctor uses the model that is adequate to the clinical situation. The seminar lists four models:

• the active-passive model (the patient is completely passive);
• the teacher-student model (control and dependence);
• the friendship model (dysfunctional);
• the mutual participation model (partnership).

In a partnership, doctor and patient:

• understand their roles and tasks;
• accept the differences in their roles and tasks;
• build a coherent entity with goals and direction;
• accept a degree of partnership.

Disease centred model

The doctor concentrates on the patient's symptoms and holds a partial view of the patient. He is seen as the expert, and the patient relies on him to overcome the illness. The physician has to decide what should be done for the patient, the physician knows best, and the patient accepts the recommendation without question. The doctor is in charge of decision-making and of giving instructions.

Patient centred model

The doctor concentrates on both the symptoms and the personality of the patient and understands the patient as a whole, an integrative whole, not simply their disease. The aim is to empower the patient with knowledge and ability to recover. This includes listening to the patient and allowing them to explain all the reasons for attending, their feelings and their expectations; shared decision making; and therapeutic plans that are explicit and agreed.

The patterns depend on how much control the doctor holds and how much control the patient holds. The seminar grid sets doctor control (low or high) against patient control (low or high). The word "conflict" sits in the middle of the grid, between the four cells.

Paternalism

Paternalism is the pattern of strong doctor control and weak patient control. The approach is typified by a doctor centred style. It relies on closed questions designed to elicit "yes" or "no" answers. The doctor uses a disease centred model and is focused on reaching a diagnosis rather than on the patient's unique experience of illness. The doctor acts as a "parent" figure who decides what he or she believes to be in the patient's best interest. This form of relationship traditionally characterised medical consultations, and at some stages of illness patients derive considerable comfort from being able to rely on the doctor in this way and being relieved of the burdens of worry and decision-making.

Consumerism

In consumerism the patient knows exactly what they want and forces the doctor into a patient centred approach. The doctor's control is weak and the patient's control is strong.

Default

Default is where the patient centred style fails. The doctor is trying to relinquish control but the patient is unwilling to accept it, and the result is an impasse (both sides low in control).

Mutuality (partnership)

In mutuality, or partnership, both doctor and patient have strong control. The doctor uses open questions to encourage the patient to talk about the complaint. The approach relies on taking time to listen and trying to understand the patient's point of view. The doctor brings clinical skills and knowledge to the consultation: diagnostic techniques, knowledge of the causes of disease, prognosis, treatment options and preventive strategies. The patient brings their own expertise: their experience and explanations of their illness, and knowledge of their particular social circumstances, attitudes to risk, values and preferences.

A further slide gives four models in a circle divided into quarters, each with a short statement of what the doctor says:

• Paternalistic model"I decide for you".
• Informative model"I give you facts".
• Deliberative model"In addition, I tell you my preferences".
• Interpretative model"I give you facts and help you to find your preferences".

The seminar treats the relationship as a process with four parts: the content and process levels of communication, transference and countertransference, defence mechanisms in illness and resistance.

Communication in the relationship runs on two levels:

• the content level: words, events and facts;
• the process level: the level of feelings and attitudes that we are not talking about or are not conscious of. It includes what occurs on the nonverbal level, the real value of words and reactions, and here-and-now reactions and relationships.

Transference and countertransference are interpersonal phenomena found in all important relationships.

• Transferencethe feelings and reactions that patients transfer into the therapeutic situation and onto the therapist from their past (family life).
• Countertransferencethe feelings and reactions that doctors transfer into the therapeutic situation and onto the patient; reactions to the patient's transference.

Transference

Transference was first described by S. Freud, who indicated its importance for psychoanalysis in understanding the patient's feelings. It is the process whereby a person unconsciously displaces onto individuals in his current life those patterns of behaviour that originated with significant figures from childhood. It is manifested as an erotic attraction towards a therapist, but also in many other forms: rage, hatred, mistrust, parentification, extreme dependence, or placing the therapist in a god-like or guru status. A modern social-cognitive perspective explains that transference occurs in our everyday life.

Countertransference

Countertransference includes:

• inappropriate boundaries;
• the patient being attracted to the therapist or vice versa;
• accepting gifts or giving gifts;
• giving out a home address or phone number to the patient;
• too much sympathy;
• encouraging client dependency;
• non-acceptance or avoidance.

People unconsciously use mental processes to protect themselves from realities that cause conflict and anxiety. The patient's use of defence mechanisms can act as a barrier to the physician in gaining the patient's compliance. They represent intrapsychic distortions of reality: avoidance, suppression or distortion of unacceptable parts of reality. The end product of mobilising defences may be unadaptive behaviour or symptoms.

• Denialthe patient unconsciously refuses to admit to being ill or to acknowledge the severity of the illness. Denial can be destructive in the long term if it hinders the patient from seeking treatment.
• Regressionthe patient reverts to a more child-like pattern of behaviour that may involve a desire for more attention and time from the physician. It can make the patient more dependent and less able to take decisions regarding his or her illness.
• Affective isolationpatients declare that they have no bad feelings; this is connected with a risk of overreactions.
• Accusingparanoid reactions.

Resistance is the patient's opposition, conscious or unconscious, to the doctor's efforts and to the changes that treatment asks of them. It shows as missed or late appointments, silence or changing the subject, argument, or not following the agreed plan. It is often the outward result of the defence mechanisms above, so it is met with understanding of what the patient is protecting themselves from, and not with confrontation.