There is considerable healing power in the physician-patient alliance. Working together offers the opportunity to significantly improve the patient's quality of life and health status. This therapeutic alliance involves specific and important physician obligations.
What is a fiduciary relationship?
Fiduciary derives from the Latin word for "confidence" or "trust". The bond of trust between the patient and the physician is vital to the diagnostic and therapeutic process. It forms the basis for the physician-patient relationship. In order for the physician to make accurate diagnoses and provide optimal treatment recommendations, the patient must be able to communicate all relevant information about an illness or injury. Physicians are obliged to refrain from divulging confidential information. This duty is based on accepted codes of professional ethics, which recognize the special nature of physician-patient relationships.
How has the physician-patient relationship evolved?
The historical model for the physician-patient relationship involved patient dependence on the physician's professional authority. Believing that the patient would benefit from the physician's actions, a paternalistic model of care developed. Patient's preferences were generally not elicited, and were over-ridden if they conflicted with the physician’s convictions about appropriate care.
During the second half of the twentieth century, the physician-patient relationship has evolved towards shared decision making. This model respects the patient as an autonomous agent with a right to hold views, to make choices, and to take actions based on personal values and beliefs. Patients are acknowledged to be entitled to weigh the benefits and risks of alternative treatments, including the alternative of no treatment, and to select the alternative that best promotes their own values (for further discussion, see Informed Consent).
Will the patient trust me if I am a student?
Students may feel uncertain about their role in patient care. Building trust requires honesty: students must be honest about their role, letting the patient know s/he is a physician-in-training. In some settings, an attending physician or resident can introduce the student to initiate a trusting relationship. In other settings, students may need to introduce themselves. One form of introduction would be "Hello, I am Mary Jones. I'm a third year medical student who is part of the team that will be caring for you during your hospitalization. I'd like to hear about what brought you into the hospital." (For further discussion of this issue, see Student Issues.)
Many patients appreciate the opportunity to work with the student on the team. Students usually have more time to spend with a patient, listening to the patient's history and health concerns, and may become more aware of personal concerns than other team members. Patients notice and appreciate this extra attention.
How much of herself should the physician bring to the physician-patient relationship?
Many patients may feel more connected to a physician when they know something of the physician’s life, and it may sometimes be appropriate to share information about family or personal matters. However, it is essential that the patient, and the patient's concerns, be the focus of every visit.
What role should the physician's personal feelings and beliefs play in the physician-patient relationship?
Occasionally, a physician may face requests for services, such as contraception or abortion, which raise a conflict for the physician. Physicians do not have to provide medical services in opposition to their personal beliefs. In addition, a nonjudgmental discussion with a patient regarding her need for the service and alternative forms of therapy is acceptable. However, it is never appropriate to proselytize. While the physician may decline to provide the requested service, the patient must be treated as a respected, autonomous individual. Where appropriate, the patient should be provided with information about how to obtain the desired service.
What can hinder physician-patient communication?
There may be many barriers to effective physician-patient communication. Patients may feel that they are wasting the physician's valuable time; omit details of their history which they deem unimportant; be embarrassed to mention things they think will place them in an unfavorable light; not understand medical terminology; or believe the physician has not really listened and, therefore, does not have the information needed to make good treatment decisions.
Several approaches can be used to facilitate open communication with a patient. Physicians should:
- sit down
- attend to patient comfort
- establish eye contact
- listen without interrupting
- show attention with nonverbal cues, such as nodding
- allow silences while patients search for words
- acknowledge and legitimize feelings
- explain and reassure during examinations
- ask explicitly if there are other areas of concern
What happens when physicians and patients disagree?
One third to one half of patients will fail to follow a physician's treatment recommendations. Labeling such patients "noncompliant" implicitly supports an attitude of paternalism, in which the physician knows best (see: Difficult Patient Encounters). Patients filter physician instructions through their existing belief system and competing demands; they decide whether the recommended actions are possible or desirable in the context of their everyday lives.
Compliance can be improved by using shared decision making. For example, physicians can say, "I know it will be hard to stay in bed for the remainder of your pregnancy. Let's talk about what problems it will create and try to solve them together." Or, "I can give you a medication to help with your symptoms, but I also suspect the symptoms will go away if you wait a little longer. Would you prefer to try the medication, or to wait?" Or, "I understand that you are not ready to consider counseling yet. Would you be willing to take this information and find out when the next support group meets?" Or, "Sometimes it's difficult to take medications, even though you know they are important. What will make it easier for you to take this medication?"
Competent patients have a right to refuse medical intervention. Dilemmas may arise when a patient refuses medical intervention but does not withdraw from the role of being a patient. For instance, an intrapartum patient, with a complete placenta previa, who refuses to undergo a cesarean delivery, often does not present the option for the physician to withdraw from participation in her care (see: Maternal-Fetal Conflict). In most cases, choices of competent patients must be respected when the patient cannot be persuaded to change them.
What can a physician do with a particularly frustrating patient?
Physicians will sometimes encounter a patient whose needs, or demands, strain the therapeutic alliance. Many times, an honest discussion with the patient about the boundaries of the relationship will resolve such misunderstandings. The physician can initiate a discussion by saying, "I see that you have a long list of health concerns. Unfortunately, our appointment today is only for fifteen minutes. Let's discuss your most urgent problem today and reschedule you for a longer appointment. That way, we can be sure to address everything on your list." Or, "I know that it has been hard to schedule this appointment with me, but using abusive language with the staff is not acceptable. What do you think we could do to meet everybody's needs?"
There may be occasions when no agreeable compromise can be reached between the physician and the patient. And yet, physicians may not abandon patients. When the physician-patient relationship must be severed, the physician is obliged to provide the patient with resources to locate ongoing medical care.
When is it appropriate for a physician to recommend a specific course of action or override patient preferences?
Under certain conditions, a physician should strongly encourage specific actions. When there is a high likelihood of harm without therapy, and treatment carries little risk, the physician should attempt, without coercion or manipulation, to persuade the patient of the harmful nature of choosing to avoid treatment.
Court orders may be invoked to override a patient's preferences. However, such disregard for the patient's right to noninterference is rarely indicated. Court orders may have a role in the case of a minor; during pregnancy; if harm is threatened towards oneself or others; in the context of cognitive or psychological impairment; or when the patient is a sole surviving parent of dependent children. However, the use of such compulsory powers is inherently time-limited, and often alienates the patient, making him less likely to comply once he is no longer subject to the sanctions.
What is the role of confidentiality?
Confidentiality provides the foundation for the physician-patient relationship. In order to make accurate diagnoses and provide optimal treatment recommendations, the physician must have relevant information about the patient's illness or injury. This may require the discussion of sensitive information, which would be embarrassing or harmful if it were known to other persons. The promise of confidentiality permits the patient to trust that information revealed to the physician will not be further disseminated. The expectation of confidentiality derives from the public oath which the physician has taken, and from the accepted code of professional ethics. The physician's duty to maintain confidentiality extends from respect for the patient's autonomy.
Would a physician ever be justified in breaking a law requiring mandatory reporting?
In general, mandatory reporting requirements supersede the obligation to protect confidentiality. While the physician has a moral obligation to obey the law, she must balance this against her responsibility to the patient. Reporting should be done in a manner that minimizes invasion of privacy, and with notification to the patient. If these conditions cannot be met, or present an intolerable burden to the patient, the physician may benefit from the counsel of peers or legal advisors in determining how best to proceed. (For a discussion on the limits of confidentiality, see the topic page on Confidentiality.)
What happens when the physician has a relationship with multiple members of a family?
Physicians with relationships with multiple family members must honor each individual's confidentiality. Difficult issues, such as domestic violence, sometimes challenge physicians to maintain impartiality. In many instances, physicians can help conflicted families towards healing. At times, physicians work with individual family members; other times, they may serve as a facilitator for a larger group. As always, when a risk for imminent harm is identified, the physician must break confidentiality.
Physicians can be proactive about addressing the needs of changing family relationships. For example, a physician might tell a preteen and her family, "Soon you'll be a teenager. Sometimes teens have questions they would like to discuss with me. If that happens to you, it's okay to tell your parents that you'd like an appointment. You and I won't have to tell your parents what we talk about if you don't want to, but sometimes I might encourage you to talk things over with them."
The physician-family relationship also holds considerable healing power. The potential exists to pursue options that can improve the quality of life and health for the entire family.
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Related discussion topics: Confidentiality, Difficult Patient Encounters, Informed Consent, Maternal-Fetal Conflict, Professionalism, Student Issues
Core clerkship material for: Family Medicine | Orthopedics | Otolaryngology | Surgery | Urology
MaryJo Ludwig, MD
Clinical Faculty, Department of Family Medicine
Resident Faculty, Valley Medical Center, Renton
Wylie Burke, MD, PhD
Facutly, Bioethics & Humanities