20 May

The Qualities of the Doctor Patient Relationship
For as long as it takes.

If, as Shakespeare wrote, “All the world’s a stage,”1 and if each encounter between a patient and a physician is a drama, great or small, and if the pa- tient is the center of the drama, then from these simple premises flow a number of inferences:

•  Patients need help. If they could handle or solve their problems alone, using their own resources, they would not have come to the physician. In order to help, physicians must be certain to define the problem correctly.

•  The physician must speak the patient’s language, not vice versa. What physi- cians say to patients must be comprehensible.

•  The physician must start where the patient is, not the other way around. At- tending  to  this  simple principle—an  axiom  of the  social work profes- sion—guides the entire transaction  and keeps the process centered on the patient.

•  The patient’s needs are to be met, not the physician’s, though doctors need to be happy in their work.

•  The patient’s problems are the subject of the transaction. They are not inter- ested in hearing a parallel story from the physician’s life.

•  Patients could not care less whether theirs is an “interesting case.”

What the physician does with the information obtained about the pa- tient—the  history, physical examination, and ancillary data—is process. Ultimately the results of this process come back to the transaction between the patient and the physician. And so it is worthwhile to describe the doc- tor-patient  relationship in depth. It is not simply “being nice to the pa- tient.”

If you doubt that the relationship has importance, think of this: The re- lationship allows the physician to do painful things—press down hard on a really painful abdomen, for instance—without  retaliation. It allows inti- mate  examination—an   examination  of  the  rectum,  pelvis, or breasts—without cries of assault. Think also about these questions:

•  If there were just a few things that doctors could do that were really effective be- fore the early twentieth century, when there was a real acceleration of technol- ogy and availability of effective drugs and other kinds of therapy, how come people went to doctors back then?

•  If the relationship is important to the outcome of the illness, to the patient, and to the patient’s family, could we do without it?

•  What do physicians do when they have done nothing concrete; that is, they have not given the patient a prescription or done a procedure?

In the previous chapters, I have described in detail what it is like to be a patient and to be a physician. What does each bring to the doctor-patient encounter? Patients bring:

•  Their needs and fears. What to the physician may be a self-limited illness with a good prognosis—abdominal pain from gastroenteritis, for instance—may mean to the patient that he has cancer. It is up to the physician to discover those fears of discomfort, uncertainty, and outcome.

•  Their experiences. If encounters with other physicians have turned out well, their expectations will be similar for the current one, and they will likely be at ease. But if their experiences have been unpleasant or inconsistent, if prior phy- sicians have been moody, unavailable, and incomprehensible, it will be no wonder that the patient may be tentative, suspicious, and argumentative.

•  Their prejudices, positive and negative. “What kind of name is yours?” some- one with positive or negative expectations of an ethnic group, race, gender, or manner of dress may ask. Dislikes based on prejudice may not last once time en- riches the relationship, but such impressions may overpower the initial encoun- ter.

•  Their unstated agendas. “I’m here for an examination before my knee surgery” may disguise the concern that “this means I’m getting older and beginning to

fall apart.” A simple question from the physician, “What does this surgery mean to you?” can expose these fears.

•  Their goals and expectations. “I want to be completely healed” may be the un- spoken goal, or “I just want to make it to my daughter’s wedding. Then I’ll be content.”

•  Their values and those of the communities to which they belong.

•  Their strengths and resources or lack thereof. They carry with them the knowl- edge of the ways they have met adversity and the successful strategies they used to solve them. They bring the experiences and examples of family and friends. “When my mother was ill with cancer, she handled it in an admirable way by… .” They bring the support of family and friends and their religion or philos- ophy of life.

To the encounter, physicians bring:

•  Their credential, M.D., their technical expertise, and their humanity.

•  Their prior professional experiences. After all, the reason the patient has come to a physician is because the doctor is experienced in dealing with such problems; the patient is not.

•  Their prejudices. Though physicians ought to be prejudice-free, many are not.

At the very least, though, they need to recognize their prejudices and neutralize them during the doctor-patient encounter.

•  Consistency. Not “hot” one day and “cold” the next. Though the patient may be volatile and labile from one encounter to the next, the physician is consis- tent and therefore trustworthy. “I am the same. I will never lie to you. I will not abandon you,” are the unspoken reassuring messages of this consistency.

•  Calm at a time of upset, disarray, and uncertainty for the patient.

•  Their own special strengths. Beyond the broad physician credential, they may be known for their expertise in a specialty, a subspecialty, or a particular illness, or their ability to listen, address the needs of the elderly or the rebellious teen- ager, or see the patient in the broad biopsychosocial context.

•  What they have learned from life. As with the patient, there is more to physi- cians’ lives than time spent in professional encounters. Successes and failures are potentially intrusive—for good or bad—on professional lives.

•  Their values and those of the communities to which they belong, just as with patients. They are members of the medical community, to be sure, but they also may have religious values, “midwestern values” (in my own case), or others that flavor the way they treat patients.

•  Fears. Of death, of making a mistake, and of failure.

Two generations ago, the most common model of a doctor-patient rela- tionship was a paternalistic one: The physician told the patient, “This is what’s wrong, and this is what you should do.” Not much was negotiable. Implied was, “The doctor knows best.” A far more acceptable model is “the enhanced autonomy model”2 in which the patient and the physician are partners. There are no directives from the doctor to the patient; rather, there is an ongoing negotiation, integrating data, diagnosis, treatment op- tions, and values. “Let’s come to an understanding of what’s going on. Let’s both be sure we’re reasoning from the same information. Let’s be sure we have the same goals. Let me tell you what I think and then we’ll negotiate.” Most patients appreciate this approach.

Whatever the medical issues, the success of the transaction ultimately depends on the quality of the relationship between the physician and the patient. As we sharpen our ability to characterize that relationship, we can learn from our successes and mistakes, make use of our insights, and teach what we do.

Compare these two decisions (Table 19.1):

•  Decision A. Whether  to have an appendectomy for acute appendicitis, an acute illness for which surgery is almost always the only treatment and is almost always effective. Even in the elderly patient with many chronic illnesses, the chance of a bad outcome is small.

•  Decision B. Whether to have palliative chemotherapy for breast cancer with widespread metastases. “Palliative” means that the treatment will not cure the illness; it may only delay its progression. Certain types of chemotherapy have substantial adverse side effects: nausea, loss of appetite, hair loss, and other or- gan toxicity. With chemotherapy, often there are no guarantees of success.

What is the role of the physician? How important is the relationship be- tween the patient and the physician?

For the patient with appendicitis, the transaction is simple, involving few uncertainties. The outcome with treatment is almost always good. On the other hand, the patient with the malignancy needs ongoing physician involvement, understanding, inquiry into her values, and recognition that the decision to accept or reject the chemotherapy is not irrevocable. It is insufficient for the doctor to say, “Here are your choices. Take your pick.” Over the duration of the illness, the physician provides validation, support, and the promise of future availability and keeps the patient from unneces- sary or futile procedures. For the series of transactions to be most effective, they need a relationship.

Table 19.1

Comparison of Some Qualities of Appendicitis and Metastatic Breast


*Morbidity: Duration and severity of the illness

If the prognosis is poor, then the relationship is especially important in sustaining the patient and family for the duration of the illness. Even when “nothing more can be done”—that is, no further treatment specific for the cancer—there is plenty more to do. The physician provides comfort, sup- port, perspective, and interpretation.

Empathy is a primary quality of the relationship. A rabbi told me this story, one of my favorites: Two boys, the son of a rabbi and his best friend, decide to play a game. “You be the rabbi,” says the son of the rabbi, “and I’ll be his congregant.” “Rabbi,” the “congregant” says, “I’m having trouble in my marriage, trouble with my boss, and trouble with my daughter.” Replies the “rabbi,” “You should pay more attention  to your wife, confront your boss, and make peace with your daughter.” To which the rabbi’s son replies, “No, no, no, you didn’t do it right. You didn’t first say, ‘Oy!’ ”

I reminded myself of the story often while I was in practice. As a less ex- perienced physician, my inclination  was to provide the remedy without first acknowledging the patient’s feelings, struggles, and reaction to the di-lemma. I learned. That is not to say that the first word from my mouth has always been “Oy!” But it has been an “oy equivalent,” an expression of em- pathy. A former student told me about this experience in medical school: “While I was accompanying a staff physician, his patient told him of his dis- comfort from his malignancy and his fears. Though the patient was clearly in distress, the physician listened without reaction. Almost without think- ing, I said to the patient, ‘This must be very hard for you.’ From that mo- ment on in the interview, the patient spoke directly to me and seemed more relaxed.”

“The most effective relationships are based on respect, trust and can-dor.”3 The absence of any one of these three elements undermines the ef- fectiveness of relationships. Honest  discussion enhances  relationships. Patients want to trust their physician. Even when the news is bad, the phy- sician can  be honest  about  diagnosis, treatment  (“These are difficult choices”), prognosis (“Things  aren’t going well”), psychosocial issues (“You seem depressed; am I reading you right?”), and the relationship itself (“I sense that we’re not getting along and I’d like to figure out why”).

But patients cannot trust without feeling that they are trusted. It is hard enough to forsake control by entering a hospital or a nursing home; imag- ine what it must be like if the patient does not trust the doctor, the nurse, or the institution.  In turn, the physician should expect complete honesty from the patient. And so every transaction becomes a deposit in a “trust fund.” Every transaction is an opportunity either to build or to undermine a trusting relationship. Honesty is one dimension of trust. Some patients have thought it necessary to tell their doctor, “Don’t keep anything from me.” Left unstated, that worry may linger and attach itself to each transac- tion. The wise physician says, “I will always be honest with you, for I know that if you ever catch me in a lie, it will be very difficult to reestablish trust.” Start where the patient is. This story, in which the patient’s daughter was his surrogate, illustrates how we can get into conflict by ignoring this axiom.

A demented 91-year-old man became tremulous and more breathless at the nurs- ing home. There was no “do not resuscitate” order, and so the patient’s nurse called me, and I called his daughter to report the change. Her wishes: Do everything, use a ventilator and resuscitate if necessary. I hospitalized the patient, and because he needed a ventilator to support his breathing, I consulted a pulmonary disease spe- cialist who said he thought the high-technology efforts were a waste of resources for old people, when we live in a community with limited funds.

Whose views should take precedence, the daughter’s or the consultant’s? What were the issues? Was it cost, prejudice against old people, or paternal- ism? Was it a difference in the perception of the worth of the old man? For the consultant, the worth had to do with cost to the community. For the daughter, it had to do with her relationship with her father; even though he was demented, he remained an important presence in her life. The daugh- ter and the pulmonary disease specialist saw the dilemma differently.

This interaction was made more difficult because both of us physicians, new to the drama, had no relationship with the daughter, and she needed an ally. We placed her father on a ventilator, and though he died during that hospitalization, the additional time (and money) allowed the daugh- ter to deal with the potential loss. Challenging a point of view without ade- quate information can undermine the relationship; a far better course is to seek understanding and accommodation. During that time, the physicians and the daughter established an alliance and a shared point of view.

The relationship provides entrée to the medical system. In relation to the entire system of care, the primary physician is the “general contractor” and the patient’s advocate. Especially when a complicated illness requires hospitalization and several consultants, the primary doctor becomes the fi- nal common pathway for information. Unless one physician is in charge of the message, the patient may get confusing signals from different sources. This story illustrates:

A 60-year-old bachelor had neglected his health for years and was beginning to ex- perience the complications of diabetes, including an infected foot that would not heal. Not one to use fear as a treatment “weapon,” I reassured him that with proper treatment and care his foot would heal. My plan, in the long run, was to use this in- cident and its good outcome as positive reinforcement to alter his style of living. I asked a dietitian to counsel him regarding diet. He repeated to me her exact words: “If you don’t take care of yourself, you could lose a foot.”

Continuity, knowing the patient over time, is an important dimension. Recall from chapter 1 the patient’s requests on the eve of his coronary ar- tery bypass surgery: “Of each of my physicians, cardiologist, and surgeon, I asked for continuity of care—that each would see me daily and be avail- able, rather than a surrogate. I did not want decisions about my care to be made by someone who did not have a complete perspective about me medi- cally. I wanted to be looked after by someone who knew who I was. I did not want too many cooks spoiling the broth. I did not want to feel abandoned.” When I had to tell my 64-year-old patient that his chronic kidney prob- lem had progressed to the point where he now needed dialysis, we were able

to have a straightforward conversation. His prior illness had been a long one, and now his wife was seriously ill also. I realized that he and I had a trusting relationship, built up over time, and we could use that relationship in making a difficult decision.

I recognize that patients and families think things over between visits to the doctor, and we ought not necessarily expect an immediate change in an opinion or behavior. If they are not having symptoms, they think about whether or not to have the recommended surgery. They think about the implication of a diagnosis of cancer, heart trouble, or hypertension. At first they may be overwhelmed by the diagnosis, but usually they deal with it in a healthy manner, accept it, and move on to the next step.

Continuity is important, not only for the patient, but also for the physi- cian. When I admitted an 80-year-old woman to the hospital for terminal care, I recognized that this was not simply another hospital admission but also the end of her daughter’s long struggle to care for her—a terminal mo- ment for her daughter also. To appreciate the significance of this drama en- riched the experience for me and enlarged the opportunities to help each of them. It was important to be able to say to myself, “I know you and I can ap- preciate what you are going through.” That  comes with continuity and time. Continuity  also allows the physician to ruminate about a case, to come up with new insights about the diagnosis and treatment.

Even without the benefits of time, we can develop relationships, espe- cially at moments of great need. I heard this story from a psychiatrist who specialized in caring for patients disabled by industrial accidents.

A young man came to the physician for the first time immediately following an in- jury to his left wrist. After briefly reviewing the history of the injury, the physician proceeded with his examination. Gently holding his uninjured right arm, he care- fully palpated it from elbow to wrist, and declared, “This feels normal.” The patient thought, “This doctor at least knows normal from abnormal.” Then the doctor ex- amined the injured left arm, starting at the elbow, away from the area of pain. By the time his examining fingers reached the injured, tender wrist, the patient had developed trust in the competence and gentleness of the doctor.

“Think of what it would have been like for the patient,” the psychiatrist suggested, “had the physician gone straight for the injured wrist.”

This next story is more complex.

A 60-year-old woman saw me for the first time for hypertension, which required medication. After a week, she returned with a more normal blood pressure, but de- scribed two brief periods in which she had difficulty speaking. These episodes strongly suggested the diagnosis of a “transient cerebral ischemic attack,” related to  carotid  artery  narrowing.  Events  rapidly unfolded.  She  had  a  cerebral angiogram, which showed substantial narrowing of one carotid artery. I referred her to a neurologist who felt, as I did, that the treatment of choice was carotid ar- tery surgery; without it, we felt, she was at risk of a serious stroke. But during the surgery, she had a stroke.

Two challenges arose in this brief relationship, the first one almost im- mediately. How should I, a doctor new to the woman and her family, pres- ent the need for surgery? What I said was, “Here we are, we’ve hardly met, and I’m already recommending surgery for an illness that’s causing you no pain. I recognize how difficult that decision must be for you.” Then I went on to explain the details of the difficulty, how the treatment for hyperten- sion had uncovered the previously “silent” (i.e., without symptoms) arte- rial narrowing, and what the course of her illness might be, treated and untreated. I explored her values. I explained the risks. By doing all of these things, I enhanced my credibility as an involved physician—and not just a technician.

The second challenge was far more difficult. How was I to tell her family that their mother had a stroke during the procedure that was supposed to prevent just such an event? By encouraging her to take this step, we had precipitated this catastrophe. How was I to present this bad news and at the same time deal with their guilt—and mine? First I acknowledged the bad outcome and expressed my sadness. Then I retraced all the steps leading to our  decision: the  first inkling  of the  difficulty, the  findings on  the angiogram, the prognosis of her difficulty with and without treatment, the choices available to us—surgery or medication, and the consensus of all the physicians regarding the best choice. Of the outcome, I said, “You wouldn’t be human if you didn’t ask, ‘Did we, the family, do the right thing?’ Like you, I feel badly that this happened. In my mind I retraced all of our steps, and I believe we all made what we thought was the best choice.” I also helped the family recognize that the process of dealing with this loss—of good health, speech, and use of one side of her body—takes time.

During the next six months, the patient partially recovered. The rela- tionship,  created urgently and quickly, helped get her and her family through this drama. She remained my patient, and other family members became my patients.

The nurse-midwife’s creed refers to “being with the patient for as long as it takes.” This is another way of saying to a patient, “I will not abandon you.” The relationship between the physician and the patient is the key to the human side of medicine.

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