Doctor-patient relationship

Healing – Long Term Relationships

I’m back to my series of posts about healing relationships. Hopefully it will not be necessary to return to posts about COVID, but if new developments happen that require some explanation, I will go back to posting about COVID.

In our dysfunctional health care system, health systems seem to think that clinicians are interchangeable like widgets. Since healthcare is a product, it does not matter who provides the product. Relationships between clinicians and patients are nice, but not really necessary. Many primary care organizations make very little attempt to make sure that patients are scheduled with their own clinician when they make appointments. As we shall see, clinician-patient relationships, the longer the better, are not only nice but essential for both patients and clinicians.

It used to be common for clinicians to stay in their communities for a long time. I started doing family medicine in Batesville, Arkansas in 1979 and stayed there for twenty years. That is distinctly uncommon today. Clinicians (both doctors and nurse practitioners) move every few years.

I am convinced that the healing aspect of clinician-patient relationships takes years to fully develop. In my own experience, I think it takes at least five years for me to begin to develop healing relationships with my patients. It can happen more quickly with patients who have chronic illnesses and need to be seen frequently, but that is the exception rather than the rule.

Abiding

In my research patients and doctors talked about how important it is for patients to feel that they are known by their physicians, that is known as people, not just a vehicle for disease. Knowing someone takes time. We used the term “abiding” to describe these long term relationships. It is a kind of intimacy that both clinicians and patients described as like being members of a family. Here is how one patient described abiding: “I think after years and years and years and years it’s like…a marriage. You and your doctor have a marriage.” Another patient said, “She knows who I am first of all. She knows exactly who I am. She knows my thoughts and my way of understanding things.” One doctor described abiding this way: “There’s being there for the big events, whether that’s birth or death or the diagnosis of something bad, or being there when they need you to be there, pushing other things away in order to be there in a way that’s more substantial.”

Abiding also means not abandoning patients even when all the pills and technology have been tried and patients are still suffering. If just listening to a patient’s story of suffering and having compassion for him/her is all that a clinician can do, then he/she needs to do that. As I discussed before, curing may not be possible, but healing can still happen. As one patient said, “He never gave up on me. And that means a lot.”

Trust

Trust means feeling safe. It means that you can tell your clinician anything and you will not feel judged. It means confidence in the competence of your clinician. It means knowing that promises will be kept. It takes time for trust to develop. As one physician said, “That’s something that you can’t do right away. You have to sort of earn that.”

Earning trust does not meant that trusted clinicians never make mistakes. But when they do make a mistake they tend to admit it. That often actually enhances trust. As one patient said, “He had the courage to say, ‘Well, I made a mistake.’ That endeared him to me forever.”

What to look for in your doctor

If you are lucky enough to have a trusted clinician who has been with you for a long time, then treasure that relationship. Always insist on seeing that clinician unless you have an emergency and your clinician is not available. There is nothing you can do to keep your clinician from moving or retiring, but to the best of your ability, choose someone who has been in your community for a long time, because that clinician is more likely to value long term relationships with patients.

Healing – Understanding Power in Doctor Patient Relationships

It seems to me that many healthcare organizations assume that doctor/patient encounters are transactions between equals. Much of the healthcare organization language reflects this idea. Doctors and nurse practitioners are called ”providers.” That is supposed to be inclusive language, but rather than that, it characterizes doctors or nurse practitioners as providing something (health care) to consumers (patients). While empowering patients is a laudable goal, characterizing the clinician-patient encounter as similar to selling shoes is not. I prefer the term clinician, which includes doctors and nurse practitioners.

I want to be clear that I am not advocating for a return to the paternalistic (perhaps authoritarian is a better word) model of “Doctor knows best.” This kind of relationship, where the doctor decides what the diagnosis is and what the treatment will be without regard for patient’s preferences or values is disappearing (although not fast enough) and good riddance to it.

On the other hand, there is an inherent asymmetry of power in relationships between clinicians and patients and pretending that it does not exist will not make it go away. When patients are ill, frightened that something bad may be wrong with them, they do not comparison shop. They go to a clinician they feel like they can trust to help them. A good clinician provides the best science in diagnosis and treatment tailored to this particular patient; her values, her preferences, her personality.

Empowering patients

Good clinicians empower the patient as much as possible. They do this in several ways. They listen carefully as I discussed in the previous post. They create a partnership with patients. As one patient said in one of my interviews, “one thing I really appreciated with [my doctor] is like we’re a partnership.” 

Good clinicians also empower patients by translating medical jargon into understandable language and by giving them information they can use to manage their own illness. As one patient said, “He explained what I needed to do going forward, the life change it would take, you know the medication, the eating habits, and everything to try and keep it from happening again.”

Using clinician power

Sometimes, clinicians need to carefully use power to push resistant patients to take actions that are important for their health. As one patient with HIV infection said, “…that’s why I really need, someone to push me, tell me you have to do those things. That’s one of the reasons that I’m still here.”

Good clinicians have an intuitive understanding about when and how to push patients based on assessments of patients’ needs and strength of relationships. One physician described it this way: “…sometimes you’re the coach and sometimes you’re the boss and sometimes you’re the sibling and sometimes you’re the doctor.”

What to look for in your doctor

Here are some red flags that suggest you should look for another doctor.

  1. Your clinician has already made up her mind about treatment and pays no attention to your concerns.
  2. Your clinician lectures you about your bad health habits
  3. Your clinician gives you whatever medicine you ask for that you have found on the internet without discussion of whether it is appropriate for you.
  4. Your clinician uses medical jargon that you don’t understand.

There are good clinicians out there that know how to use power appropriately in the context of relationship. Most of the time that means empowering patients, but it also means knowing when to push when necessary for the patient’s benefit. If you don’t have one like that, keep looking.