Why Fix the Lopsided Clinician-Patient Relationship?

Tom G. Bartol, MN


November 04, 2019

Shared decision-making (SDM) isn't always as easy as it sounds. Is that because patients have read too much yet understand too little about their health, and there just isn't enough time to set them straight? Or do patients just want to be told what to do?

The traditional approach to SDM has been to provide high-quality information, often using decision aids and tools, to enable patients to make informed choices about their own care. But the missing ingredient, suggest Pavlo and colleagues, and what may be even more transformative in the SDM collaboration, is how much balance exists in the relationship between clinician and patient.

They recommend replacing unilateral information-sharing with a relational model that not only provides information but also accounts for the patient's personal values, preferences, goals, and experiences—factors that are unique to each patient. When patients, especially those with serious mental illnesses, are seen as more than their diagnoses, they are better prepared to engage in making decisions about their health.


Economists use the term "information asymmetry" to describe a situation where one party in a transaction possesses greater knowledge about something than the other party. The classic example is a used-car dealer. The dealer knows all about the car: where it came from, what is wrong with it, and how much it is really worth. The customer knows little about the car or its condition beyond what can be seen—the cleaned and polished exterior. The balance of power (in this case, establishing what the car is worth) shifts to the person with the most information.

Information asymmetry exists in healthcare interactions between patient and clinician as well. Patients know far less than clinicians about health, illness, and treatments, so they often defer to clinicians when decisions about their care must be made.

But there's another type of information asymmetry in the clinician-patient relationship. The clinician may know more about health and disease, but the patient knows more about his or her own life, circumstances, desires, values, and experiences. True SDM requires that this information imbalance be addressed. If it is not, there's a risk that the clinician will consider the patient to be noncompliant with treatment, when the real problem is a lack of relationship-building by the clinician. In relationship-centered care, the individual person is treated, rather than the disease. Patients feel respected, trusted, supported, and more able to take part in decisions about their care.

Tom Bartol is a family nurse practitioner doing primary care in rural Maine. He is also a nationally known speaker and author sharing insights about healthcare and clinical practice.

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