There is considerable healing power in the physician-patient alliance. A patient who entrusts himself to a physician's care creates ethical obligations that are definite and weighty. Working together, the potential exists to pursue interventions that can significantly improve the patient's quality of life and health status.
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 these medical 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 patient's preferences were generally overridden or ignored. For centuries, the concept of physician beneficence allowed this paternalistic model to thrive.
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 have been increasingly 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 the topic page on
Will the patient trust me if I am a student?
Students may feel uncertain about their role in patient care. However, it is crucial for building trust that you begin this relationship in an honest and straightforward manner. A critical part of this is being honest about your role and letting the patient know you are 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 the Student Issues topic page.)
Many patients will feel quite close to 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 patients certainly notice and appreciate this extra attention.
How much of herself should the physician bring to the physician-patient relationship?
Many patients appreciate a physician who brings a personal touch to the physician-patient encounter. They may feel more connected to a physician whose extracurricular activities and interests make her seem more alive. Physicians choose to share parts of their life stories according to their level of comfort. 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, it is acceptable to have a nonjudgmental discussion with a patient regarding her need for the service, and to ensure that the patient understands alternative forms of therapy. 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 resources 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. Patients filter physician instructions through their existing belief system; 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 hard 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 the Maternal/Fetal
Conflict topic page). In most cases, choices of competent patients
must be respected when the patient cannot be persuaded to change
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; with concern for mental incompetence; 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?
Legal obligations to break confidentiality may pose difficult
choices. While the physician has a moral obligation to obey the
law, he must balance this against his responsibility to the patient.
It is essential to balance the duty to protect the patient's confidence
against the physician's responsibility to the members of the public
at risk. (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.