The  World Medical Journal (2015) 61: 28-31

Lost in Translation?
The doctor-patient-relationship revisited

Beneficial medical treatment is based on a trustful therapeutical relationship between doctor and patient. This does not just happen by itself, but must be developed with competence and maintained with care. Through the ages, the way doctors and patients meet and interact has undergone substantial changes, with every era posing specific challenges.  


The Patient: help-seeking sufferer or critical consumer?

The traditional view is strongly paternalistic. Bound to the Hippocratic oath, the fatherly physician is commited to the patient's well being, his own best possible skills, personal integrity and privacy. "Salus aegroti suprema lex" (the well-being of the patient is the supreme law) and "primum nihil nocere" (first of all do not harm ) are the principle professional rules. As a benevolent father-figure, it is the doctor who decides.  

Enlightment and The French Revolution brought about a fundamentally egalitarian approach. Questioning authoritative rule eventually leads to the, nowadays, widely accepted concepts of "informed consent" and "shared decision making",  promoting patient competence and autonomy. Negotiating disagreements becomes possible, the prevention of abuse and exploitation of the subordinate easier. Instead of command and obedience, two individuals with equal rights make a contract. And finally, it is the patient who decides.  

Sounds good, but where does this leave us? The egalitarian model is easily applied to buyer and seller at the marketplace, where the buyer looks for a certain product or service and makes an informed decision after having checked price and quality. But is a patient's need for aid when in distress and crisis the same thing as buying a new vacuum cleaner, a favourable mobile phone tarif or an attractive spa package?  

The more fit a patient is, the more he is able to act like a competent consumer. By means of the internet he is sometimes better informed about specific details than his doctor. The greater a patient’s distress however, and the younger, older or more sick he is, the less important autonomous negotiating might be for him.  

Between doctor and patient, duties and responsibilities are shared in a very asymmetrical manner. Unlike the doctor, whose health remains in a comfortable and safe position, the patient, may be in a situation of life and death, his physical integrity in question as well as having responsibilities for loved ones. So in everyday medical practice, a third option must often be considered: The patient wants the doctor to decide for him.  

This doesn't make things easier, however.  


The doctor: trustworthy medic or top salesman?

Medical doctors still hold a high social status in public opinion polls and achieve remarkable income levels. Enormous technical progress has added to the reputation of the profession. Consequently, doctors are confronted with high expectations by society as a whole and by the individual patient.  

But something has gone wrong. Numerous publications highlight serious deficits in medical care, pointing to an increasing mutual alienation between doctors and patients. A gap of mistrust seems to have opened. Patients have become cautious because they know or have heard of doctors motivated by pressure from their administrations and lured by bonus payments to prescribe more expensive drugs, more lucrative diagnostic interventions and higher-priced surgical procedures; all potentially harmful. Alternative medicine may seem less of a hazard.  

At the same time, patients seem to be fighting back. We are seeing a surge in malpractice and negligence suits, and many collegues feel the pressure of receiving bad patient ratings in online portals.  

To heal the breach of trust, doctors must account for the current state of medicine and decide which kind of medical care they actually prefer.


Medicine: human science or technical engineering?

Today, academic medicine is going through a dramatic structural change which is characterized by the rule of economy,  bureaucracy and technology. Bernard Lown, renowned cardiologist, compellingly describes the far-reaching consequences for everyday medical practice in his book "The lost art of healing" (1). We are confronted with a radical erosion of human medicine in its original sense. What is lost, is the specifically human element.  

It seems as if the trustful and sustainable doctor-patient-relationship has become a side issue. In this way medicine is losing its soul and becoming a technical engineering craft. In addition, clinical procedures are often Tayloristically elaborate, not only in operating theaters, but wherever they are performed.  

Such a development is not without consequences for the status of a profession in society. By means of historical examples, Richard Sennett describes the social decline of once highly respected professions (as was the case with the potter profession in ancient Greece), which is caused by increasing dominance of purely technical processes using mainly manual labor (2).  

In this respect, it is highly alarming that personal and “talking medicine” is increasingly outsourced to non-medical professions (pedagogues, psychologists, social workers, etc.). Alongside, and to the detriment of, Cardiology, Oncology or Diabetology we see the establishing of non-medical Psycho-Cardiology, Psycho-Oncology or Psycho-Diabetology. Instead of the present traditional family doctor, we might soon see a non-medical family therapist taking over the verbal and general counselling care.  

This split is something patients definitely do not want. It's simply of no use to a suffering patient to have on the one side the medical equivalent of a  plumber or clockmaker to repair the broken engine and on the other side a friendly talking psycho-conversation-partner, who doesn't know any more about the subject matter at stake than the patient himself. After a myocardial infarction,  with the diagnosis of breast cancer or with a threatening somatoform symptom, a patient has a justified wish to be cared for by a doctor, who is both medically competent and compassionate. It is an appallingly distressing experience for a patient, in a short session, to be fully informed, according to all legal standards, about the diagnosis of, for example, malignant lymphoma by the responsible oncologist and then to be sent afterwards to an appointment with a psycho-oncologist to talk over the emotional elements.  

The consequence of this is that frustrated patients turn away from scientific medicine, and unhappy doctors seek jobs outside medical care in research, counseling, journalism or administration.


Patients and doctors - strangers or friends?

It makes no big difference if doctor and patient meet for the first time in an emergency room, strangers to one another, than if they had already had a couple of appointments in the assessment of rectal hemorrhage, if they collaborate on a regular basis in the treatment of rheumatic arthritis, or if they are even engaged in a psychotherapy meeting once a week.  

Whatever the setting, they face the demanding task of establishing a trustful and sustainable relationship. Coming from two very different worlds, the patient with his suffering, the medical problem and his psycho-social history and the doctor with his medical expertise and the promise to help, they have to get acquainted with one another in order to accomplish the common goal of relief, or hopefully even healing.  

Numerous challenges have to be met. The average conversation time in a personal contact between patient and doctor is said to be less than ten minutes. After fifteen seconds the patient's speech is interrupted, either by the doctor's questions, or having to check the computer monitor, or other tasks such as filling in forms (3). Only half of the information conveyed by the doctor is properly understood by the patient and half of this again forgotten after half an hour. It is perfectly clear that medicine by the minute leaves no room for sufficient understanding, let alone exchange.  

This is in strong contrast to the requirements of adequate medical care and efficient treatment.


The psychosomatic approach

About ten percent of the urban population suffer from psychosomatic disorders, mostly somatoform disorders with functional somatic syndromes accounting for the majority (4). The prevalence in family doctor's practices goes up to some thirty or forty percent and reaches up to sixty percent in secondary care, e. g. specialised neurological or gynecological units (5). The clinical spectrum ranges from chronic pain syndromes such as headache or back-pain, over syndromes with compromised organ function such as vertigo, tinnitus, arrythmias, hyperventilation, irritable bowel or sexual dysfunction, to more generalised pictures such as agitation or burn-out (6). Psychocomatics considers the crucial role of emotional factors in pathogenesis here.  

If speaking with a patient is considered important, then listening is indispensable. Being in tune with the patient, applying the art of careful active listening, means listening with the "third ear". This enables the doctor to understand subliminal, hidden messages and to discover those problems the patient is not yet able to communicate in an open and direct manner. As Balint put it, if the patient could clearly name his problem, he would not have to present a symptom (7).  

Patients with psychosomatic disorders are especially difficult to deal with. Whereas “ordinary” patients might be expectant and vulnerable, psychosomatic patients in particular are additionally prone to feeling disappointed, insulted, hurt and abandoned by their doctor. Often limited in their abilities to adequately express their fears and wishes, they make their medical counterpart offer help by proposing medical actions in the form of prescribing drugs, suggesting additional diagnostic procedures or even recommending surgical interventions.

Doctors do so especially when confronted with affect-laden signals from their patients, for example, when confronted with statements like, "Doctor, I can't stand this back pain anymore", "my head is burning like fire", or, "this tears my heart into pieces". Overstrained and overwhelmed by the patient's relational attitude it seems a way out is to at least present a medical “gift” (8). "Ut aliquid fiat" (to do something) may be one of the most frequent indications in medicine. As one collegue put it, "sending that patient to another CT-scan bought me one month of peace and quiet". This example shows that doctors, in their desperation, sometimes reject their patients by sending them to unnecessary examinations or referring them to another colleague. If in the back of the patients mind is the notion that evidence based medicine cannot understand their suffering and is even rejecting them, then alternative medicines gain appeal, which is a dangerous trend if left unchecked.  

In order to offer these patients adequate care, skills and knowledge in understanding and handling patients emotionally difficult for the doctor are necessary. Doctors' widespread wish to offer comprehensive help, including somatic and psycho-social support, is specifically realized in Psychosomatic Medicine. Apart from specialist training, there are several opportunities. Balint-groups and courses in primary psychosomatic care are especially helpful for every physician responsible for medical care, whether it be conservative medicine or surgery.  

As Edward Weiss wrote in 1943, the crucial point in psychosomatics is "not to study the soma less; it only means to study the psyche more" (9).


Literature

1.   Lown B. The Lost Art of Healing. Houghton Mifflin. 1996

2.   Sennett R. The Craftsman. Yale University Press. 2009  

3.    Bär T. Die spontane Gesprächszeit von Patienten zu Beginn des Arztgesprächs in der hausärztlichen Praxis. Dissertation, Charité 2009  

4.   Schepank H: Psychogene Erkrankungen der Stadtbevölkerung – eine epidemiologische Studie in Mannheim. Heidelberg , New York , London , Paris , Tokyo : Springer 1987.

5.   Nimnuan C, Hotopf M, Wessely S. Medically unexplained symptoms. An epidemiological study in seven specialities. Journal of Psychosomatic Research, 2001, Volume 51, Issue 1, 361-367

6.   Henningsen P, Zipfel S, Herzog W. Management of functional somatic syndromes. Lancet. 2007 Mar 17;369(9565):946-55.

7.   Balint, M. The doctor, his patient and the illness. London , Edinburgh Churchill Livingstone. 1957.  

8.   Ring A, Dowrick C, Humphris G, Salmon P. Do patients with unexplained physical symptoms pressurise general practitioners for somatic treatment? A qualitative study. BMJ 2004;328:1057

9.   Weiss E. Psychosomatic Aspects of Allergic Disorders. Bull N Y Acad Med. 1947 Nov; 3(11): 604–630.