In her April President’s Comment [BCMJ 2018;60:143], Dr Trina Larsen Soles does not express any fear that she will be replaced by a machine, but she feels that our profession needs balance: “science is essential, but the art lies in how we use it in the practice of medicine.”
She asks for restoration of a “healthy medical culture that supports us all to be healers in the truest sense of the word.”
Searching for the meaning behind the art of a doctor-patient relationship, and the ideal model for medical practice, is like looking for the “The Lost Chord.”
The doctor-patient relationship evolved from ancient Egyptian times. Healers were as much magicians and priests as doctors, establishing a parent-child type of active/passive practice style with sick people.
This healer’s style remained dominant for thousands of years in the context of minimal social and technical change. By the time of the ancient Greeks, the democratic form of social organization led to a guidance/cooperation type of medical practice. Doctors of the time followed the Hippocratic oath: “The regimen I adopt shall be for the benefit of my patients according to my ability and judgement.”
Several thousand years went by without much change. By Medieval times, including the time of the Crusades and the witch hunts, the doctor-patient relationship regressed to the parent-child style. Governed by religious beliefs and the reacceptance of magic, sick people were regarded as helpless without doctors’ magical powers.
The Greek guidance/cooperation type of practice returned in Europe with the Renaissance, which boosted the search for equality, human dignity, and the rise of empirical science. By the early 18th century another change occurred. Symptoms became the illness. There were few doctors, and patients were mostly from the aristocratic class. As patients, the members of that social class became dominant in the medical relationship. Doctors treated the symptoms of their masters. Hospital settings were created for the underprivileged, where authoritarian doctors ruled. Arising from their observations over many years, a new theory emerged: the symptoms were the indicators of underlying pathology, although it took another 100 years for developments in microbiology, anesthesia, and surgery to improve the health of the symptomatic.
By the mid-19th century, examination of the patient’s body became important, and doctors’ expert knowledge made them universally dominant over the ignorant and passive patients across all social classes, turning the clock back to the paternalistic model of medical practice.
By the late 19th century psychological theories begin to focus on the patient as an individual. It became fashionable to listen to the patient. Doctors began to treat the sick as persons needing reassurance, guidance, and enlightenment. As we reached the 20th century following the First World War, a physician’s interest in humanity and care for their patients became essential, but still without the important scientific or technical advances in medicine that were to follow.
Doctors became involved in a large range of problems, beyond the biomedical ones. In the years after the Second World War the practice of medicine changed again. Physical exams, hands-on treatments, house calls, applications of new but still human-scale technology, which could be understood by patients, led to a mutually appreciated relationship. The doctor and the patient were seen as influencing each other, with the doctor’s physical presence and actions being of major therapeutic importance.
Today, amid the rise of complex advances in medical science and technology, along with instant messaging and video, we try to guide our practice according to various perspectives, including evidence-based medicine, translational medicine, narrative medicine, personalized medicine, precision medicine, and the latest entrant, evolutionary medicine.
We have yet to see how these changes will affect the core doctor-patient relationship, and if technological gains will be limited by the loss of the inherent healing properties of the clinical relationship. The doctor’s direct patient work involves verbal and nonverbal behaviors, and the importance of touch, exemplified by the use of the stethoscope or the palpation of the abdomen. Equally important is the physician’s awareness that a patient cannot deduce the doctor’s problem-solving and diagnostic skills without being informed and being provided an opportunity to ask questions and demonstrate an understanding of the answers. This requires the one resource that every busy practitioner has in short supply, time. And under-communicating risks a rupture of trust, which, in turn, has been implicated in a decrease in compliance and positive health behaviors.
Not being able to see what goes on in the doctor’s brain—how in a matter of minutes the doctor untangles historical observations, physical and laboratory findings, the doctor’s clinical and life experiences, present work pressures, and a host of other factors—the patient may feel abandoned. Short visit times, the one-problem-per-visit type of appointment, engagement of a number of highly trained related professionals in longer-term care, excessive wait times for needed procedures, and a number of other factors add to the perception that the doctor-patient relationship is becoming unglued. The computer is also blamed. In an office visit, patients react poorly when the doctor focuses on computer data entry instead of facing the patient.
I think the writing is on the wall. The evolution of medical practice will lead to a much-increased appreciation of the doctor’s ability to bring scientific and technical knowhow to diagnosis and curative medicine. But it will be the rising group of related professionals who might become the primary listeners—the gatekeepers, the first responders, and the long-term care givers.
I think that might work out quite well.
—George Szasz, CM, MD
I gratefully acknowledge Dr Jonathan Fleming’s review of my blog post and his contribution to the clarification of some of my thoughts.
Emanuel EJ, Emanuel LL. Four models of the physician-patient relationship. JAMA 1992;267:2221-2226.
Kaba R, Soorikumaran P. The evolution of the doctor-patient relationship. Int J Surg 2007;5:57-65.
Larsen Soles T. The art and heart of medicine. BCMJ 2018;60:143.
This posting has not been peer reviewed by the BCMJ Editorial Board.