Toward a Biopsychosocial Understanding of the Patient–Physician Relationship: An Emerging Dialogue (original) (raw)

The Doctor-Patient Relationship Revisited

Annals of Internal Medicine, 1973

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The patient–physician relationship: an account of the physician’s perspective

Israel Journal of Health Policy Research

Background: The issue of patient-physician relationships in general, and particularly the trust of patients in their primary care physician has gained much interest in academia and with practitioners in recent years. Most research on this important topic, however, focused on how patients view the relationship and not how the physicians see it. This research strives to bridge this gap, with the resolution of leading to an improved appreciation of this multifaceted relationship. Methods: A survey of 328 actively practicing physicians from all four health maintenance organizations (HMOs) in Israel resulted in a hierarchical formation of components, indicating both the relative as well as absolute importance of each component in the formation of the patient-physician relationship. The sample conducted was a convenience one. Methodologically, we used two different complementary methods of analysis, with the primary emphasis on the Analytic Hierarchical Processing (AHP), a unique and advanced statistical method. Results: The results provide a detailed picture of physicians' attitudes toward the patient-physician relationship. Research indicates that physicians tend to consider the relationship with the patient in a rather pragmatic manner. To date, this attitude was mostly referred to intuitively, without the required rigorous investigation provided by this paper. Specifically, the results indicate that physicians tend to consider the relationship with the patient in a rather pragmatic manner. Namely, while fairness, reliability, devotion, and serviceability received high scores from physicians, social interaction, friendship, familial, as well as appreciation received the lowest scores, indicating low priority for warmth and sociability in the trust relationship from the physician's perspective. The results showed good consistency between the AHP results and the ANOVA comparable analyses. Conclusions: In contrast to patients who traditionally stress the importance of interpersonal skills, physicians stress the significance of the technical expertise and knowledge of health providers, emphasizing the role of competence and performance. Physicians evaluate the relationship on the basis of their ability to solve problems through devotion, serviceability, reliability, and trustworthiness and disregard the "softer" interpersonal aspects such as caring, appreciation, and empathy that have been found to be important to their patients. This illustrates a mismatch in the important components of relationship building that can lead to a loss of trust, satisfaction, and repeat purchase.

A conceptual model of physician-patient relationships: a qualitative study

In any clinical encounter, an effective physician-patient relationship is necessary for achieving the desired outcome. This outcome is successful treatment, and therefore, the relationship should be a healing one. In addition, in the Islamic view, the physician is a manifestation of God's healing attribute, which is usually undermined in everyday therapeutic communications. Yet there are few empirical data about this experience and how it occurs in the clinical context. This study was conducted to develop a model of physician-patient relationship, with the healing process at its core. Our goal was to explain the nature and characteristics of this encounter. In Islamic teachings, healing is defined as " cure " when possible and if not, reducing pain and suffering and ultimately finding a meaning in the illness experience. This study was a qualitative inquiry. Data were collected through 17 open-ended, semi-structured interviews with physicians who had an effective relationship with their patients. The participants' experiences and their perception regarding the relationship were subjected to grounded theory content analysis. For establishing the trustworthiness of the data collection and analysis we used triangulation, peer review, and member checking. The findings showed that the components of the patient-physician healing relationship could be categorized in the four key processes of valuing the patient as a person, effective management of power imbalance, commitment, and the physician's competence and character. This leads to forming the three necessary relational elements of trust, peace and hope, and being acknowledged. Their importance has been better demonstrated in a relationship which incorporates the spiritual aspects of patient care and also physician's satisfaction. The physician-patient relationship has a central role in patient outcome. This relationship has an understandable structure and its components may have an effective impact on promoting the patient's experience of the health system.

Beyond the Biopsychosocial Model New Approaches to Doctor-Patient Interactions

The Journal of Family Practice, 1999

BACKGROUND. The biopsychosocial model has been a cornerstone for the training of family physicians; however, little is known about the use of this model in community practice. This study, conducted in an urban Native American health center, examined the application of the biopsychosocial model by an experienced family physician (Dr M). METHODS. Interactions between Dr M and 9 Native Americans with type 2 diabetes were audio-recorded following preliminary interviews. Interpretations of the interactions were elicited from Dr M through interpersonal process recall and interpretive dialogue sessions. The author analyzed this data using techniques from interpretive anthropology and narrative discourse analysis. RESULTS. In a preliminary interview, Dr M described a sophisticated biopsychosocial approach to practice. However, she viewed her actual interactions with these patients as imbued with misunderstanding, mistrust, and dis connection. This occurred in spite of her experience and commitment to providing culturally sensitive primary care. CONCLUSIONS. Biopsychosocial models of disease may conflict with patient-centered approaches to communica tion. To overcome difficulties in her practice environment, Dr M adopted a strategy that combined an instrumental biopsychosocial approach with a utilitarian mode of knowing and interacting with patients. The misunderstandings, mistrust, and constrained interactions point to deeper problems with the way knowledge is formed in clinical practice. We need further understanding of the interrelationships between physicians' clinical environments, knowledge of patients, and theories of disease. These elements are interwoven in the physicians' patient-specific narratives that influence their interactions in primary care settings.

Complexity and Healing Relationships

Journal of General Internal Medicine, 2006

The Institute of Medicine's first simple rule for quality health care is a long-term healing relationship; and the first aim for a quality health care system is patient-centered care. 1 The Association of American Medical Colleges' Medical School Objective Project urged faculties to teach interpersonal and communication skills. 2 The Accreditation Council for Graduate Medical Education accredits residency programs based, in part, on their demonstration of residents' competence in interpersonal and communication skills. 3 Similarly, the American Board of Medical Specialties' member boards include communication skills in the criteria for certification and recertification. 4 Yet the scientific and theoretical basis for these recommendations remains sparse. The proceedings of the conference, ReForming Relationships in Health Care: Creating a National Research Agenda for Relationship-Centered Care, published in this supplement contributes to rectifying this deficiency. The plenary papers explain how, why, and what makes healing relationships succeed and fail. The conference outlines an ambitions agenda of research questions about the centerpiece of all health carethe healing relationship. The answers to these questions promise to inform healers, teachers of healers, evaluators of the quality of healing, and social institutions that support healing. The philosophy of medical care called relationship-centered care (RCC) provides the ideological glue that holds these papers together. 5 On superficial inspection RCC appears to be a synonym for its antecedent, and possibly more familiar patient-centered care or the humanistic qualities of Care. Such short shrift would be unfortunate, for RCC plows new ground by expanding the concept of the physician patient relationship to one that includes the personhood of both the patient and the physician, acknowledges the central role played by the emotions of both parties in the relationship and the fact that the relationship is shaped by reciprocal influence rather than only by humanistic, but still largely unidirectional, therapeutic ministrations. Were the RCC philosophy to stop with expanding the ideas about the physician patient relationship, it still would be a substantial advance; however, its authors go further. They promote the idea that health care emerges from the relationships between all of the people who make up the institutions and communities responsible for health care. In all of these relationships, the personhood, emotions, and reciprocal influences of everyone on everyone else actively shape the quality of care, the experience of health and illness, and satisfaction of everyone involved. 6 At first blush, RCC appears to challenge the basic tenants of traditional medical professionalism. It displaces the old idea that physicians be compassionate yet somewhat depersonal

Problems and Prospects in the Study of Physician-Patient Interaction: 30 Years of Research

Annual Review of Sociology, 2006

■ Abstract Working within the functionalist perspective that he did so much to develop, Parsons (1951) conceptualized the physician-patient relationship according to a normative framework defined by the pattern variable scheme. As Parsons clearly recognized, this normative conceptualization was one that empirical reality at best only approximates. In the 1970s, two major studies established doctor-patient interaction as a viable research domain. In the present review, we consider approaches to the medical interview developing from these initiatives and that have a primary focus on observable features of doctor-patient interaction. Within this orientation, we consider literature dealing with social, moral, and technical dilemmas that physicians and patients face in primary care and the resources that they deploy in solving them. This literature embodies a steady evolution away from a doctor-centered emphasis toward a more balanced focus on the conduct of doctors and patients together.

An analytic review of the doctor-patient relationship part I

Romanian Journal of Bioethics, 2009

bioethics models of doctor-patient relationship. I have argued that the bioethics models of doctorpatient relationship are normative and prescriptive in nature and that the effectiveness of different models to promote their assumed goals is not assessed empirically. In this part of the review, I analyse different clinical models of doctor-patient relationship with the aim of understanding the relation between the theoretical and philosophical arguments behind different models of doctor-patient relationship with the empirical evidence on the effectiveness of different models to promote their goals if implemented at the level of health care. The process in the DPR is at the core of the clinical models of DPR, namely patient-centred care model (PCC) and relationship-centred care model (RCC) [1]. Since its inception more than fifty years ago through the early work of Balint [2] and Engel [3] clinical models of DPR have gained a high profile in general practice and are considered a central feature of quality practice [4].In this section, I analyse through an ethical lens the concepts and ideas that are commonly described and empirically studied in the literature surrounding the clinical models of DPR. I argue that clinical models of DPR, similarly to bioethical models of DPR, are prescriptive and normative in nature. First, I describe and analyse from an ethical point of view the patient-centred care (PCC) model of DPR. I argue that some of the ethical meanings of the different dimensions of this model are not made clear by its proponents. Second, I describe and outline the relation-centred care (RCC) model of DPR and the empirical research surrounding the process in DPR. I describe the communication patterns that characterize RCC and outline the empirical research on their effectiveness to promote beneficence and patients' autonomy. I argue that there is some evidence that a process in DPR characterized by these communication patterns could promote both benefice and patients' autonomy. Third, I compare the clinical and bioethics models of doctor-patient relationship. I argue that the similarities between Brody's relational model of doctor-patient relationship and RCC model of doctor-patient relationship may suggest that the implementation of this model at the level of care could be effective to promote both beneficence and patient autonomy.