Does a Real Physician-Patient Relationship Exist Anymore?

Debra A. Shute

December 10, 2019

William Gilkison, MD, family physician from Indianapolis, still has feelings of rejection after a young family he treated decided to switch to another physician – with no warning signs.

It was decades ago, when Gilkison had just begun his career. Many of his early patients had been referred to him by another local doctor who had retired, and life was good.

"I felt blessed that so many new families were coming my way," he said. Two parents and their four children under the age of 16 — seemed to Gilkison like a perfect fit. He imagined that he'd care for all of the members of this family for years.

But after a few visits, with no warning signs, the matriarch of the family sent the practice a written notice requesting that their records be sent to another doctor.

"Years later, I still have feelings about that rejection," he said, adding that so early in his practice, he generally assumed that all of his patients would like him. "To some degree, I guess the loss is similar to losing a patient [who dies] in that you don't ever see them again."

Gilkison eventually learned that patients choose and leave doctors for a variety of reasons.

For sure, doctor/patient relationships are often not what they used to be. Whereas patients used to stay loyal to their physician for a long time, today it's common that if their employer's insurance changes, the patient switches to a new doctor. And because visits are often shorter than they were in the past, doctors and patients have less conversation time to build a relationship. The situation became even worse when doctors began spending visit time typing into an electronic health record (EHR) and eye contact lessened.

And yet, in the Medscape Physician Compensation Report 2019, physicians revealed that gratitude from and relationships with patients topped the list of what made their jobs rewarding. So it's not surprising for a physician to feel the sting of a patient's leaving so acutely.

Patient Interactions Will Vary

"Forming relationships with people, having someone come in and learning about their work or where they have traveled, getting to know them a bit on the nonmedical side has become in a lot of ways more important and more fun," said David Neiblum, MD, a gastroenterologist in West Chester, Pennsylvania. For some physicians, these priorities emerge as they become more masterful at the clinical side of caregiving, said Neiblum. "A lot of doctors will say that the longer you do something, the more routine it gets," he said.

What makes a fulfilling physician-patient relationship varies among physicians. For Neiblum, his role is to tune in to the patient in terms of what he or she is looking for in a doctor. "You want to gauge their personality, mostly to get them to trust you, so that they will share things and be receptive to your recommendations."

For example, while a hard-charging CEO might expect direct answers to a lot of tough questions, a patient with a history of drug abuse could require more trauma-informed care.

In other cases, patients come in afraid their symptoms indicate cancer. "My job is first to make sure they don't have cancer, but second to calm them down and reassure them that chances are higher that they don't have something terrible," he said. "Building trust is absolutely essential."

A New Factor in Doctor/Patient Relationships

In a recent survey about what makes a strong physician-patient relationship, the top answer was, "we share decision-making and collaborate on treatment plans" (20%), followed closely by "visits are warm and friendly with good communication" (19%).

The notion of shared decision making is relatively new in medicine, noted Adam Cifu, MD, professor of medicine and associate dean of medical school academics at the University of Chicago. "I think physicians [today] expect a more collaborative relationship with patients," he said. "Whether they like it or not, that's the reality. For the most part, it's very positive."

Collaboration in medicine has become so important that the Society for Participatory Medicine (SPM) released a Participatory Medicine Manifesto, signed by physician attendees at its 2019 annual conference, held in Boston.

In doing so, these physicians pledged their commitment to share and listen; respect one another; share information responsibly; promote curiosity; and be a team builder.

As a result of this evolution, patients come in armed with more information and often clearer expectations, Cifu said. "It's sometimes a challenge, though, because that's the cultural shift in how we've educated the current generation of physicians."

The tricky part comes in when a patient prefers for physicians to give them recommendations to follow, Cifu said. In other situations, it might be clinically necessary for a physician to overrule a patient. "It's funny that these days, I find that it takes some teaching to get trainees to say, 'This is the situation, and this is the right treatment,' because they've been schooled so much in patient autonomy that it's often harder to shift when necessary."

What Actually Makes the Relationship Work?

To make a physician/patient relationship satisfying, both parties need to feel involved and respected.

Consistent with survey results, many physicians valued patient-physician communication as a chief factor in building a relationship.

"From a patient's perspective, the most important things are knowing that you're going to be heard and that a real effort is going to be made to get the appropriate care for you that's personalized to your values," Cifu said.

Importantly, physicians also want to be heard. "Physicians often get frustrated with their relationships because people come in with a preformed idea about what's going on and what should happen; and when they don't get that, they get aggravated," Cifu said. "Then you hear doctors say, 'Why do they come for my advice if they don't want to hear it?' "

Physicians often get frustrated with their relationships because people come in with a preformed idea about what's going on and what should happen; and when they don't get that, they get aggravated. Dr Adam Cifu

To head off this problem, some physicians ask new patients to tell them what they expect from them as a doctor. And some physicians will lay out their expectations for the patient as well. "It's an interesting way to begin a relationship, but I think it's not a bad one," Cifu said.

Why Is It Sometimes Hard to Bond?

Barriers to connecting with patients are pervasive. Some problems are endemic to the medical system itself. "Insurers sometimes make it difficult to really treat someone," said Neiblum. For example, payers may put up roadblocks to ordering certain tests, or the best medication to treat a patient's condition may not be covered by his or her insurance.

"These problems with modern medicine can get in the way of the relationship," Neiblum added. But there are ways physicians can repair fractured patient relationships, including a letter of apology.

During a panel discussion at this year's SPM conference about missed connections in healthcare, audience member Ashley Clayton, MA, director of research and evaluation at the Center for Wellbeing of Women and Mothers in the Department of Psychiatry at the Yale School of Medicine, shared part of her struggle to access lifesaving treatment for depression. This was chronicled in a recent essay published in Health Affairs.

During the session, Clayton explained that although her difficulties were, as Neiblum suggests, connected to systemic problems, receiving a written apology from her physician made all of the difference in their relationship going forward. "It's stronger than it's ever been," she said.

Dealing With the Threat of Dr Google

Although physicians indicate that collaborative relationships with patients are rewarding, they're not always thrilled when patients attempt to diagnose themselves through Internet research or insist on a treatment recommended by a celebrity doctor.

"It's ironic," said Cifu, "because on the one hand, all you're hearing these days is about personalized medicine." This broadly means tailoring to the individual. "And the exact opposite of that is the single physician speaking to millions or people searching a generic complaint on the Internet," he said.

Nonetheless, the Web is a valuable tool that can help balance the knowledge level between physician and patient, Cifu noted. "It's not one person knowing everything and the other person knowing nothing. It helps the patient have a bit more educated conversation about it all."

If trust and clear communication have already been established in the relationship, such conversations can be productive, even if they don't result in fulfilling the patient's requests. "Ideally, the patient still needs to trust that what the doctor is saying is based on robust evidence," Cifu said. And if a recommendation is based more on a hunch, he advises telling a patient that the treatment may or may not work, along with the reasons for the suggestion.

This type of dialogue can keep both sides from getting defensive and will hopefully strengthen the relationship in the long term.

The Desire to Feel Appreciated

Medscape's poll also showed that almost all of the physicians surveyed receive some form of appreciation from their patients often or sometimes.

"I'm not surprised when people express appreciation, because they realize that the clinician is working, spending time, and thinking about how to care for them," he said. "It's clear that when physicians do a better job with patients they like, who they're invested in, that it's in everybody's best interest to have a relationship like that."

It's clear that when physicians do a better job with patients they like, who they're invested in, that it's in everybody's best interest to have a relationship like that. Dr Adam Cifu

Cifu said that he is sometimes caught off guard when patients express no appreciation to the caregiver and are also sometimes difficult. "They treat you as though they never plan to see you again."

Physicians don't expect elaborate shows of gratitude. "I've gotten cards and gifts and positive reviews over the years, but it's not expected. It's a little bit of icing," Neiblum said. "But if someone just says 'thank you' with a smile, I'm happy."

How Physicians Show Warmth to Patients

Physicians have various ways of reciprocating their feelings to patients, which include verbal confirmation, a handshake, or a hug. But it's also not uncommon for physicians to focus on the computer screen more than the patient or frequently interrupt while the patient is speaking, Neiblum said.

"It's a big problem," he said. "So I try to force myself to ask patients why they're here and wait a few minutes before I say anything. Some personal contact, like a hand on the shoulder, is very good. I'm very cognizant to talk with the patient and not get sucked into the computer."

Cifu doesn't agree that the EHR is responsible for the demise of the physician-patient relationship. He noted that many patients would be frustrated if a physician could not access their entire record right in the room.

Although physician/patient relationships may face more challenges now than in the past, they are still at the heart of the reason why physicians choose their profession. And many patients consider those relationships equally as important.

Debra A. Shute is a freelance healthcare journalist based in the Greater Boston area.

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