-Department of English-
Health Humanities Undergraduate Research
The Evolution of the Physician-Patient Relationship
Background:
In the influential novel Middlemarch, author George Eliot writes, “the medical profession as it might be was the finest in the world; presenting the most perfect interchange between science and art; offering the most direct alliance between intellectual conquest and the social good” (136). While medicine is often considered to be a discipline deeply rooted in science, many contributing factors to patient care lie in the artistic realm of the field, particularly the humanities. Therefore, researching the humanistic aspect of medicine is as important as investigating the science.
My project serves to epitomize medical humanities exploratory research for other students by viewing medicine under a humanities-based lens and analyzing a critical part of patient care: the physician-patient relationship.
Source: blogs.bmj.com/medical-humanities/
By: Devesh Malik
Purpose:
What does it mean to have a strong physician-patient relationship? Why is this dynamic important, and how does it develop? In this research project, I compiled archival and contemporary literary sources, written in the perspective of either the patient or the physician, to synthesize an evolutionary model of the physician-patient interaction; I aim to juxtapose past medical practice with that of the present to provide insight into how the patient experience has developed over time and why these changes have improved patient care.
Source: ortholive.com
Early 20th Century Medicine:
Literary Text Directly Used in Research:
A Young Doctor’s Notebook by Dr. Mikhail Bulgakov
Other Useful Texts:
The Immortal Life of Henrietta Lacks by Rebecca Skloot
Hippocratic Writings (Chapter: “Epidemics”) by Hippocrates, edited by G.E.R Lloyd
Notes on Hospitals by Florence Nightingale (founder of modern Nursing)
Johns Hopkins University Medical Archives (Chesney Archives)
New England Journal of Medicine, 1900’s editions
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In the last century, western medicine has evolved drastically; with new medical discoveries, inventions, and technologies, patient outcomes have improved tremendously. However, one characteristic of clinical medicine that is often overlooked is the interaction between patients and their doctors. When these relationships are presented in the occasional research paper, physicians are often praised for their humanistic mannerisms. Yet, archival records of the physician-patient relationship suggest that these interactions were not as commonly respectful as they are now.
Mikhail Bulgakov was a physician and writer in the early 20th century. One of his books, A Young Doctor’s Notebook, is a written record of a few of his cases as a doctor in a rural town of Russia. These records not only contain information about the medical cases, but also an autobiographical recollection of his actions and thoughts before, during, and after helping the patients. This style of record-taking allows us to enter the mind of a early 1900’s rural doctor, and analyze how they interacted with and thought about their patients.
Bedside manner is a term commonly used in modern clinical practice that refers to a doctor’s attitude and mannerisms towards their patient. In Dr. Bulgakov’s records, it was strongly suggested that this was not a concept practiced in the past, at least not in rural Russia. When a little girl was brought in by her mother and an old woman, Dr. Bulgakov was astonished to see the state the girl was in: “With every breath, hollows were being sucked in on her throat, her veins were swelling up and the colour of her face was changing from pinkish to a slightly violet hue.” (Bulgakov 33) Dr. Bulgakov was even more taken aback when he found out that the little girl was left untreated for five days, and rudely said to the mother, “‘What on earth were you thinking of?...The girl’s suffocating, her throat’s already blocked. You’ve been killing the girl for five days.’” (33-34) While it was clear from the descriptions in the record that the mother was frightened, Dr. Bulgakov seemed to only worry about informing her of her wrongdoings. Furthermore, after the old woman attempted to talk to Dr. Bulgakov, he said to her, “‘You shut up, woman, you’re being a nuisance.’” (33) In saying this, Dr. Bulgakov essentially dismissed the old woman’s input and worries. Modern medical practices show us that it is part of a physician’s responsibility to care for their patient first, yet still consider the emotions of the patient’s loved ones, especially with the family of pediatric patients. Furthermore, it is a doctor’s duty as a medical educator to properly and respectfully inform those who may not be medically literate; instead, Dr. Bulgakov looked at the uneducated old woman and thought, “‘It’d be a good thing if there were none of these old women in the world at all.’” (33) It is uncommon for laypeople to completely understand medical issues, thus it is unreasonable for Dr. Bulgakov, as a physician, to assume that anyone who is medically uneducated is not worth his energy, time, or respect.
Source: amazon.com
In medical ethics, there are four fundamental principles: autonomy, beneficence, nonmaleficence, and justice. In the case of this little girl and Dr. Bulgakov, there are no indications of anything against the latter three. Dr. Bulgakov’s efforts were clearly in favor of saving the girl, which supports the principle of beneficence. While the surgery required having “‘to cut her throat open lower down and insert a silver tube to give the girl a chance to breathe,’” (35) it is clear that this intervention was necessary for the sake of the patient’s recovery, and therefore aligns with the principle of nonmaleficence, or doing no unnecessary harm to the patient. Lastly, while the principle of justice may not be directly relevant to this individual case, it can be noted that Dr. Bulgakov chose to help the little girl and practice effective clinical care despite his resentful emotions towards the patient’s loved ones, which aligns with this bioethical concept. However, despite following these three principles, Dr. Bulgakov fundamentally neglected the first bioethical principle of autonomy, or the right to make one’s own personal medical decisions. As a pediatric patient, the little girl’s medical autonomy lies in the hands of her guardians. In the book, the mother blatantly refused intervention, saying, “‘I don’t consent!’” (35); nevertheless, Dr. Bulgakov ignored her judgement. Later, the mother is unethically coerced into providing consent by the feldsher (nurse), when he says, “‘What, are you mad? What do you mean, you don’t consent? You’re condemning the girl to die. Consent. Have you no pity?...Come on, hurry, hurry up and consent! Consent!’” (36) After berating the mother, she finally agreed to the surgery.
Source: ollieburton.com
In regards to establishing a strong physician-patient relationship, the principle of autonomy is arguably the most crucial. The other three are then important for following through with care and maintaining the depth, trust, and compassion that underlies all effective physician-patient relationships. In developing a strong relationship, it is the physician’s responsibility to acknowledge the patient’s perspective and consider it when reaching a mutually agreed upon solution, modernly known as shared decision-making. If this is not established early on in the interaction, the patient can quickly become detached from the physician, which can lead to their unwillingness to fully cooperate or share, thereby hindering the physician’s ability to care for them. Despite the relationship being shattered with the patient’s guardian and not the patient herself, this is still the essential piece missing in Dr. Bulgakov’s mannerism. His record of the surgery brought into sharp focus the immediate effect of a negative interaction when he wrote, “I felt acute regret about having entered the medical faculty and about having ended up in these backwoods. In angry despair I thrust the forceps somewhere towards the wound at random.” (38) If Dr. Bulgakov was to have a similar conflict with his patient directly, the emotional states of both the patient and Dr. Bulgakov could be affected, leading to immediate and possibly multiplicative repercussions in the patient’s treatment.
It is important to consider the entire narrative when evaluating the situation. In the case of the young girl, diagnosed with diphtheritic croup, Dr. Bulgakov properly managed the crisis and saved the patient through a difficult surgery. It is remarkable that a patient so far along in their emergent illness was successfully treated in a rural setting lacking proper medical tools and operating rooms. Yet, it is still important to highlight the ethical mistakes made in the patient’s care, how they affected the physician-patient relationship, and how they could have had detrimental effects on current and future treatment.
Modern Medicine:
Literary Text Directly Used in Research:
How Doctors Think by Jerome E. Groopman, MD
Other Useful Texts:
Deep Medicine by Eric Topol
Being Mortal: Medicine and What Matters in the End by Atul Gawande
The Two Kinds of Decay by Sarah Manguso
Published Research (PubMed database)
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Since the early 20th century, the physician-patient experience has evolved via positive changes in medical practice, namely the increased attention to bedside manner. According to a paper published in 2008 regarding doctor-patient communication, “Nowadays complete, correct and comprehensible communication is a primary exigency for the physician, for the patient/person and for all the organizational levels of the sanitary system.” (Conti) It has become more common for physicians to emphasize effective communication with their patients and respect their autonomy by including them in their own personal care. This shows the positive improvements that have been made in the physician-patient dynamic, which have bettered modern patient care.
Jerome E. Groopman is a practicing physician and author of the book How Doctors Think, which provides insight into the mind of contemporary doctors with an emphasis on the physician-patient relationship. Dr. Groopman focuses on the benefits of strong patient relationships through the stories of other physicians, but also highlights issues that still exist, such as personal biases and framing patients via quick, assumed diagnoses. In the book, Dr. Groopman introduces a powerful anecdote of a patient, Anne Dodge, who was told by many doctors that she had bulimia and anorexia nervosa. Despite claiming to follow her doctors’ recommendations for an increased diet, the physicians refused to believe her because her test results showed otherwise. Dr. Groopman discusses that, after being diagnosed with these two conditions, it was unfortunately commonplace for her doctors to view her under those diagnoses alone. However, Dr. Groopman emphasizes that “a self-aware physician knows that accepting the frame as given can be a serious error.” (22); it is critical for physicians to consider other possibilities, especially with patients like Anne. Fortunately, Anne decided to see a gastroenterologist, Dr. Myron Falchuk, who “began to question, and listen, and observe, and then to think differently about Anne’s case.” (Groopman 3) Dr. Falchuk made the conscious decision to believe his patient and consider other possible reasons for Anne’s presentation; in using a holistic approach, Dr. Falchuk developed a foundational, compassionate relationship with the patient built on trust in her narrative, which led to her correct diagnosis and saved her life.
Source: amazon.com
Source: priviahealth.com
Dr. Groopman sheds light on two critical physician characteristics that help tremendously in creating a strong relationship with a patient: humility and collaboration. Humility, or the ability to recognize one’s own faults and mistakes, allows a physician to maintain an open mind and consider all possibilities, minimizing the chances of making hasty conclusions. This leads to stronger clinical intuition and an open, inclusive relationship with the patient. (20) Furthermore, Dr. Groopman writes that, “doctors desperately need patients and their families and friends to help them think. Without their help, physicians are denied key clues to what is really wrong.” (20) Collaborating with a patient and maintaining an equal relationship with them bolsters the physician’s capacity to treat them properly.
After describing how to develop a strong relationship, Dr. Groopman discusses the traits necessary for maintaining it. For example, he clarifies that in order for a patient to effectively collaborate with their doctor, they have “to trust not only [their doctor’s] skill but also [their] sincerity and motivations’… without trust and a sense of mutual liking, Anne Dodge probably would have deflected Falchuk’s suggestions of more blood tests and an endoscopy.” (23) Without mutual trust, the relationship crumbles and the patient’s care is jeopardized. As a physician taking care of vulnerable individuals, it is their responsibility to provide the foundation of trust for the relationships to build on. Moreover, Dr. Groopman considers the communicative aspect of the interaction. He quotes Judy Hall, a social psychologist focused on researching the dialogue between doctors and patients, who said, “‘the communication piece is not separable from doing quality medicine. You need information to get at the diagnosis, and the best way to get that information is by establishing rapport with the patient.’” (Groopman 20). Hall highlights the importance of communication in maintaining the dynamic between the physician and the patient.
Conclusion and Future Directions:
“Medicine is, at its core, an uncertain science.” (Groopman 7) Therefore, it is crucial to investigate not just the academic foundation of the discipline but also the subjective aspects, such as the physician-patient relationship. From the paternalistic medical practices of the 1900’s to the respectful shared decision-making model of the 21st century, medicine as a humanistic practice has come a long way; the juxtaposition of these two systems underscores the positive changes that have been made in the field of clinical medicine and the impact that a strong physician-patient relationship can have on patient care. Nevertheless, the patient experience is not perfect. Contemporary issues in healthcare, such as shortened patient appointments due to systemic insurance restrictions, can make it difficult to cultivate these important physician-patient relationships. Furthermore, heavy amounts of paperwork can steal physicians’ time away from patients (Sanders), and computer-based healthcare systems can distract physicians during patient interactions. It was also shown that physicians tend to interrupt their patients and not engage in eye contact or have meaningful interactions because of computer use. (Rhoades) Time restraints during appointments could also be a confounding factor for this. Eric Topol, author of the book Deep Medicine, discusses the possibility of using artificial intelligence during patient appointments to eliminate the physicians’ computer-based responsibilities during interactions. This would greatly improve the patient experience and allow for stronger physician-patient relationships. Despite the great strides taken in bettering the physician-patient relationship, Dr. Groopman and Eric Topol show us that there is still more room to grow; future research and analyses of these often disregarded parts of medicine are required to provide more insight into improving the holistic treatment of patients.
Citations:
Bulgakov, Mikhail. A Young Doctor's Notebook. Alma Classics, 2012.
Conti, A A, and G F Gensini. “Doctor-patient communication: a historical overview.” Minerva medica vol. 99,4 (2008): 411-5.
Eliot, George. Middlemarch. IndyPublish.com, 2006.
Groopman, Jerome E. How Doctors Think. Houghton Mifflin, 2007.
Rhoades, D R et al. “Speaking and interruptions during primary care office visits.” Family medicine vol. 33,7 (2001): 528-32.
Sanders, James H. “How Much Paperwork Is Too Much?” American Academy of Family Physicians (AAFP), Jan. 2005.