The doctor-patient relationship is central to the practice of medicine and is essential for the delivery of high-quality health care in the diagnosis and treatment of disease. A patient must have confidence in the competence of their doctor and must feel that they can confide in him or her. For most physicians, the establishment of good rapport with a patient is important. This being said, some medical specialties, such as psychiatry and family medicine, emphasize the doctor-patient relationship more than others, such as pathology or radiology. The doctor-patient relationship forms one of the foundations of contemporary medical ethics. Most medical schools and universities teach medical students from the beginning, even before they set foot in hospitals, to maintain a professional rapport with patients, uphold patients’ dignity, and respect their privacy.

With increasing access to computers and published online medical articles, the internet has contributed to expanding patient knowledge of their own health, conditions, and treatment options. Some doctors are fearful of misleading information and being inundated by emails from patients which take time to read and respond to (time for which they are not paid).^[1] About three-quarters of the U.S. population reports having a primary care physician, but the Primary Care Assessment Survey found "a significant erosion" in the quality of primary care from 1996 to 2000, most notably in the interpersonal treatment and thoroughness of physical examinations.^[2]

Contents 1 Perspectives 1.1 Non-Western Perspectives 2 Bedside manner 2.1 Examples in the media 3 See also 4 References 5 Further Information 6 External links

[edit] Perspectives

The four great corner stones of diagnostic medicine are anatomy (structure: what is there), physiology (how the structure/s work), pathology (what goes wrong with the anatomy and physiology) and psychology (mind and behavior). In addition, the physician should consider the patient in their 'well' context rather than simply as a walking medical condition. This means the socio-political context of the patient (family, work, stress, beliefs) should be assessed as it often offers vital clues to the patient's condition and further management.

A patient typically presents a set of complaints (the symptoms) to the physician, who then obtains further information about the patient's symptoms, previous state of health, living conditions, and so forth. The physician then makes a review of systems (ROS) or systems inquiry, which is a set of ordered questions about each major body system in order: general (such as weight loss), endocrine, cardio-respiratory, etc. Next comes the actual physical examination and often laboratory tests; the findings are recorded, leading to a list of possible diagnoses. These will be investigated in order of probability.

The next task is to enlist the patient's agreement to a management plan, which will include treatment as well as plans for follow-up. Importantly, during this process the healthcare provider educates the patient about the causes, progression, outcomes, and possible treatments of his ailments, as well as often providing advice for maintaining health. This teaching relationship is the basis of calling the physician doctor, which originally meant "teacher" in Latin. The patient-physician relationship is additionally complicated by the patient's suffering (patient derives from the Latin patior, "suffer") and limited ability to relieve it on his/her own. The physician's expertise comes from his knowledge of what is healthy and normal contrasted with knowledge and experience of other people who have suffered similar symptoms (unhealthy and abnormal), and the proven ability to relieve it with medicines (pharmacology) or other therapies about which the patient may initially have little knowledge.

The physician-patient relationship can be analyzed from the perspective of ethical concerns, in terms of how well the goals of non-maleficence, beneficence, autonomy, and justice are achieved. Many other values and ethical issues can be added to these. In different societies, periods, and cultures, different values may be assigned different priorities. For example, in the last 30 years medical care in the Western World has increasingly emphasized patient autonomy in decision making.

The relationship and process can also be analyzed in terms of social power relationships (e.g., by Michel Foucault), or economic transactions. Physicians have been accorded gradually higher status and respect over the last century, and they have been entrusted with control of access to prescription medicines as a public health measure. This represents a concentration of power and carries both advantages and disadvantages to particular kinds of patients with particular kinds of conditions. A further twist has occurred in the last 25 years as costs of medical care have risen, and a third party (an insurance company or government agency) now often insists upon a share of decision-making power for a variety of reasons, reducing freedom of choice of healthcare providers and patients in many ways.

The quality of the patient-physician relationship is important to both parties. The better the relationship in terms of mutual respect, knowledge, trust, shared values and perspectives about disease and life, and time available, the better will be the amount and quality of information about the patient's disease transferred in both directions, enhancing accuracy of diagnosis and increasing the patient's knowledge about the disease. Where such a relationship is poor the physician's ability to make a full assessment is compromised and the patient is more likely to distrust the diagnosis and proposed treatment. In these circumstances and also in cases where there is genuine divergence of medical opinions, a second opinion from another physician may be sought or the patient may choose to go to another doctor.

In some settings, e.g. the hospital ward, the patient-physician relationship is much more complex, and many other people are involved when somebody is ill: relatives, neighbors, rescue specialists, nurses, technical personnel, social workers and others.

[edit] Non-Western Perspectives

In non-Western societies, the physician/patient relationship may be couched in different terms. The illness may be seen as a violation of the spiritual realm and the cure will be seen likewise as having to take place in the spiritual realm. Violation of some spiritual rule can result in illness; persons distant to the patient may have caused illness by manoeuvres in the spiritual realm, by cursing or causing another practitioner / shaman / healer to place the curse. Powerful faith in these factors can result in serious illness or cure. Spirits can be part of a culture's usual pantheon, ancestor spirits or arbitrary new spirit forces arising independently or as derived from an existing object in the real world: such as an animist spirit coming from a totem animal, mountain or other thing. As in the scientific West, the practitioner is assumed to have special knowledge or power, and is paid by the patient in some form.

[edit] Bedside manner

Bedside manner is a term describing how a healthcare professional handles a patient, and is essential in affecting the doctor-patient relationship. A good bedside manner is typically one that reassures and comforts the patient while remaining honest about a diagnosis. Vocal tones, body language, openness, presence, and concealment of attitude may all affect bedside manner. Poor bedside manner leaves the patient feeling unsatisfied, worried, frightened, or alone. Bedside manner becomes difficult when a healthcare professional explains to the patient the true diagnosis, while keeping the patient from being alarmed.

[edit] Examples in the media

• Dr. Gregory House (of the show House) has a caustic, callous bedside manner. However, this is an extension of his normal personality.
• In Grey's Anatomy, Dr. Burke compliments Dr. George O'Malley's ability to care for Dr. Bailey's baby by saying "it speaks to a good bedside manner."
• Doc Martin from the Doc Martin British TV series is a good example of a doctor with a poor bedside manner.
• In Lost, Hurley tells Jack Shephard that his bedside manner "sucks". Later in the episode, Jack is told by his father to put more hope into his sayings, which he does when operating on his future wife.
• In Closer, Larry, the doctor tells Anna when they first meet that he is famed for his bedside manner.
• In Donald Trump's 2008 celebrity-edition of The Apprentice finalie, Ivanka Trump tells Piers Morgan that he did not have a good bedside manner.
• In Scrubs, J.D is a good example of a doctor with great bedside manner, while Elliot Reid is a doctor with poor or non-existent bedside manner.
• In Star Trek: Voyager, the Doctor often compliments himself on the charming bedside manner he developed with the help of Kes.
• In M*A*S*H, Hawkeye Pierce, Trapper John McIntyre, B.J. Hunnicutt, and Sherman Potter all possess a caring and humorous bedside manner meant to help patients cope with traumatic injuries. Charles Winchester initially possesses no real bedside manner, acting with detached professionalism, until the rigors of his job help him develop a sense of compassion for his patients. Frank Burns has a poor bedside manner, constantly minimizing the seriousness of his patients' injuries, accusing them of cowardice and goading them to return to the front lines.

[edit] See also

Look up bedside manner in Wiktionary, the free dictionary.

[edit] References

1. ^ ECRI. Special Article: Internet Influence on Doctor/Patient Relationship. Health Technology Trends. June, 2006.
2. ^ Safran DG (February 2003). "Defining the future of primary care: what can we learn from patients?". Ann. Intern. Med. 138 (3): 248–55. PMID 12558375. http://www.annals.org/cgi/pmidlookup?view=long&pmid=12558375. 

[edit] Further Information

• Alexander GC, Casalino LP, Meltzer DO. Patient-physician communication about out-of-pocket costs JAMA. 2003;290:953-958.
• Alexander GC, Casalino LP, Tseng CW, McFadden D, Meltzer DO. Barriers to patient-physician communication about out-of-pocket prescription costs Journal of General Internal Medicine. 2004; 19:856-860.
• Alexander GC, Casalino LP, Meltzer DO. Physician strategies to reduce patients' out-of-pocket prescription costsArchives of Internal Medicine. 2005;165:633-636.
• Alexander GC, Lantos, J. The doctor-patient relationship in the post-managed care era American Journal of Bioethics. 2006;6:29-32.
• Pham HH, Alexander GC, O'Malley AS. Physician consideration of patients' out-of-pocket costs in making common clinical decisions Archives of Internal Medicine. 2007;167:663-668.

[edit] External links

• Report of a large summit of patients and physicians, where the ideal patient-physician relationship in the 21st century was discussed. Organised by Johns Hopkins and American Healthways in 2003
• Time Magazine article: "When the patient is a Googler" - Mary Shomons response - Trisha Torreys response