While doing my medical school clerkship in pediatric oncology on hospital wards, I noticed that some parents and patients had developed an attachment to the physician faculty member directing the pediatric oncology clinic who happened to be on hospital rounds.
I particularly remember one 11-year-old patient who complained that this doctor “did not care” about her, as he sent “fake doctors” (residents) to take care of her instead of coming himself. She was refusing to cooperate. When I suggested to the director that he visit her, he did so. He pulled up a chair by her bed and assured her that he did care about her and requested her cooperation with the residents as a favor to him. She was cooperative from that point forward.
"Patients, regardless of whether they are 11 years old or 74 years old, want to know that their physicians care about them, and sometimes this means not only showing them but also telling them."
— Kristen Fuller, MD
Getting to the heart of the relationship
The therapeutic relationship between physician and patient has been discussed and debated for decades. Many thoughts on the subject can be found in “The Basic Models of the Doctor-Patient Relationship,” published in JAMA in 1956.
That article discusses three unique patient-physician relationships—active-passive, guidance-cooperation, and mutual participation—and how they blend together depending on the particular patient, physician, and disease. It also addresses issues that remain hot topics today, such as paternalistic doctors, patient values, and shared decision-making.
Doctors and patients both have a vested interest in a good relationship. There are several factors that enter into it.
Clear information, empathic, two-way communication, and respect for patients’ beliefs and concerns could lead to patients’ being more informed and involved in decision-making and create an environment where patients are more willing to disclose information. This would give patients a feeling of more ownership of clinical decisions and of entering into a therapeutic alliance with the clinician. In the end, this could support improved diagnosis (and more timely diagnosis), as well as improved clinical decisions, and can lead to fewer unnecessary referrals or diagnostic tests.
It is important to not only be knowledgeable in your field of practice but also to be up to date on new technology or procedures. Coupled with this is the ability to share your knowledge with your patient in a manner they can understand. Being confident in your knowledge and skills when treating your patient builds their trust in you.
If you are unsure of something, ask one of your colleagues or mentors who may have a more expansive knowledge base and expertise in the area of question. On occasion, it is necessary to look something up while with the patient.
Some physicians, due to time constraints, may feel the need to look something up on the computer at the point of care. Be aware that this can affect the physician-patient relationship, depending on how it is done and on the nature of the relationship already established.
A competent physician should always want to educate and share information with their patient, and advocate to find the underlying cause of the patient’s symptoms.
We meet so many new patients that we often take this mundane, first meeting for granted. But usually, for the patient, meeting a new doctor is a huge step. When meeting a new patient, we should understand the value of making a positive, honest first impression. The patient sitting before you is more than just someone with a health disorder, and more than the qualifiers you enter into the EHR.
During this first office visit, take the time to become acquainted with your patient. Ask about their family, hobbies, support system at home, and life goals. This first impression goes a long way when forming a bond between you and your patients.
"Share a little about yourself and your life, as this encourages the patient to see the ‘human side’ of their physician."
— Kristen Fuller, MD
Being open and honest, while using words and phrases that can be readily understood, fosters good communication with your patient and their family. Give your patient your full undivided attention when they are in your office. This means not focusing solely on the computer and the EHR entry. If you need to share something with your patient that is on the computer, show them the screen so they are part of the discussion. Look directly at your patient when talking, and sit across from them rather than hovering over them.
"If you spend most of the patient visit looking at a screen and typing on the keyboard, your patient may feel invisible."
— Kristen Fuller, MD
Compassion is one of the “core virtues exemplified by the ethical physician” and is listed as such by both the Canadian and the American Medical Associations, according to a review of compassion published in BMC Palliative Care.
A compassionate physician “recognizes suffering and vulnerability, seeks to understand the unique circumstances of each patient, attempts to alleviate the patient’s suffering, and accompanies the suffering and vulnerable patient.”
Regardless of who the patient is, all patients should be equally treated with compassion and empathy, whether the physician is delivering a difficult diagnosis or discussing the management of a chronic disease. A patient should never be “talked down to” or treated condescendingly. Every patient is vulnerable when they come into your office, and each deserves the best and most compassionate care possible.
When giving a grim diagnosis, try to think of whether there is anything you can offer to make that moment bearable, whether it is addressing the pain, the person’s mental health, or their grief, or giving the patient a hug. Your patient wants to feel that you, as their physician, are on their side and that you have your patient’s back.
The term “patient-centered medicine” was introduced by Enid Balint, the wife of Michael Balint, MD, who was among the first to research the dynamics surrounding doctors, patients, and illnesses. Dr. Balint had suggested that the doctor himself—at the time, most doctors were male—was a “therapeutic drug.” Enid Balint envisioned the practice of patient-centered medicine as rooted “in the way that the doctor allows the patient to use him, rather than in the way the doctor responds to the patient by his interpretations and theories.”
"When we allow our patients to talk while we listen, they will tell us their problems, and we can further ask questions to hone in on these problems. The patient and physician can work together to determine why the problem is happening and how to treat it."
— Kristen Fuller, MD
When the physician is seen as the “therapeutic drug” or the “vessel to be used,” it permits the patient to have more decision-making power. In addition, it gives the patient the ability to be more open about their signs and symptoms, and to potentially be more compliant with the treatment plan. It puts them at the forefront of the decisions and the discussions. To be a patient-focused physician, therefore, means to view your position not as one of power, but rather as one of service to your patients.
"The good physician treats the disease; the great physician treats the patient who has the disease."
— Sir William Osler, the founder of modern medicine