The Clinician-Patient Relationship: Going Through A Change?

Today, more people want more service with their medical care. In addition, more people want more voice and choice with their medical care. The historic, traditional relationship between clinician and patient was more of a paternalistic model. The clinician diagnosed and the patient listened. The clinician prescribed and the patient complied. The clinician represented authority in a paternal way. The clinician represented success and knowledge.

The patient was visiting an oracle. Initially, the patient came to the clinician for answers regarding health. However, the relationship was so paternalistic that eventually the patient would come to the clinician to find out in what to invest money, how to vote in an election, or which car to buy. It was not rare for a family physician to be advising, counseling, directing child rearing, or offering pre-marriage advice. The family doctor was not only overseeing the health of a patient but could easily be the decisive word on any issue confronting the patient. From the perspective of the patient, "my doctor knows best” and "before we decide, let me ask my doctor” was the mantra with regard to any issue! In this paternalistic model of decision-making, the clinician made the decision independently.

One of the hallmark indications that this relationship was about to go through change was opening the PDR (Physicians’ Desk Reference) to the public. Medicine was willing to empower people with medication knowledge and thus the possibility that patients might then question judgments about choices and dosage being prescribed. This has evolved into the broad marketing of drugs over the air waves and thus gives patients more opportunity to be influenced and to "question or suggest,” which supports the developing trend of changing that old patient-doctor relationship in the hope of giving a patient more autonomy and decision-making capacity. Add to the mix the growing number of TV and radio physician talk shows in which cases, symptoms, therapies, etc., are discussed. The concern being that this encourages more "arm chair physicians.” Some might argue that supporting more patient autonomy would be a double-edged sword in that while the patient becomes more involved in the decision-making, it lays the groundwork for non-compliance.

So just what should a patient-clinician relationship model look like in order to assure constructive and acceptable decision-making while at the same time increasing the probability of compliance?

  • Traditional Paternalistic Model: The clinician was a guardian and did less explaining and more dictating. The patient’s values played less of a role.
  • Informative Model: The clinician acts as a distributor of information by explaining all of the relevant / technical information available in selecting interventions.
  • Interpretive Model: The clinician acts as a counselor and relies on and then weaves the patient’s values, after helping to interpret them, into the decision making process.
  • Deliberative Model: The clinician defines, judges, and prioritizes the patient’s values when making decisions.

We probably would like to mix and match (or blend) so that when making a decision, we incorporate the patient’s values (unlike the paternalistic model), yet rely on the patient to interpret and prioritize his/her own values (as in the interpretive model) without defining the patient’s values for him/her (such as the deliberative model).

The importance of the type of relationship between clinician and patient is not just for the sake of diagnosing and prescribing, but paving the way for compliance as well. Properly diagnosing and then adequately prescribing is not the extent of our responsibility to the patient. Compliance is equally important once the patient leaves our contact and is on his/her own taking a medication or engaging in a rehabilitative regimen or going through a recuperative process. Our personality and behavior will go a long way in establishing credibility and trust in us so that the patient is more apt to comply.

The changes taking place in human behavior, influenced by changes in media and communications, are indicating that we, as clinicians, can no longer depend on standing out as an "all-seeing oracle” and deciding what the patient should do and expecting no questioning of our decisions.

The clinician-patient relationship is going through change and we certainly want to make it as mutually advantageous as possible.


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