User:NEUwikiLL/Doctor-patient relationship


 * This page currently has a fair number of sections, but the contents of each are either very biased or contain absolute statements, are lacking sufficient (or any) sources, and are not phrased well - I plan to improve each of the existing sections along these dimensions.


 * Under the "Aspects of relationship" section, I plan to add the following subsections with the respective information/topics derived from many of my literature review sources and findings:
 * Medical or physician mistrust - negatively correlated with many desirable aspects of the patient-provider relationship, like patient self-disclosure, adherence, etc.
 * Physician race (*unsure if I want to include this here, or under an existing section - very open to feedback about this)
 * Race concordance positively impacts minority individuals in many cases and enhances adherence
 * Minority patients also sometimes prefer white doctors for various reasons (higher ascribed intelligence/prestige, desire to keep a social distance between themselves and provider)
 * Physician communication style
 * Physician self-disclosure begets patient self-disclosure, likeability, higher physician ratings, intention to adhere to treatment, intention to continue using the provider
 * Response to emotional expression (passive, allowing for patients to elaborate vs. explicit or even avoidant)
 * Patient-centered communication (asking patient to 'teach-back', being warm, asking elaborative questions, encouraging emotional discussions, and demonstrating interest in the patient’s life, etc.)
 * *Perhaps* I will include a discussion of physician preparedness for discussing identity-sensitive issues e.g. gender, race, disability disparities in health/healthcare (not sure if this would better fit elsewhere or simply be omitted altogether)


 * Under the section "Physician bias" I plan to add the following information:
 * Microaggressions - overidentification, assigning unique status, stereotypic assumptions, etc.
 * Differential communication styles with minority vs. white patients
 * Minority patients report worse perceived quality of care by physicians
 * Minority patients report worse involvement in treatment decisions and information received about medications


 * Under the "Patient behavior" section, I intend to add a subsection about patient communication style/responses including a discussion of indirect self-disclosure and emotional expression, and how that may pose a barrier to communication and recognition by the physician / impede the relationship and shared decision making

Below, I have begun editing a couple of the existing sections - see the talk page for a brief overview of the changes made so far.

Importance
A patient must have confidence in the competence of their physician and must feel that they can confide in them. For most physicians, the establishment of good rapport with a patient is important. Some medical specialties, such as psychiatry and family medicine, emphasize the patient–physician relationship more than others, such as pathology or radiology, which have very little contact with patients.

The quality of the patient–physician relationship is important to both parties. The doctor and patient's values and perspectives about disease, life, and time available play a role in building up this relationship. A strong relationship between the doctor and patient may lead to frequent, freely-offered quality information about the patient's disease and as a result, better healthcare for the patient and their family. Enhancing both the accuracy of the diagnosis and the patient's knowledge about the disease contributes to a good relationship between the doctor and the patient. In a poor doctor-patient relationship, the physician's ability to make a full assessment may be compromised and the patient may be more likely to distrust the diagnosis and proposed treatment. The downstream effects of this mistrust may include decreased patient adherence to the physician's medical advice, which could result in poorer health outcomes for the patient. In these circumstances, and also in cases where there is genuine divergence of medical opinions, a second opinion from another physician may be sought, or the patient may choose to go to another physician that they trust more. Additionally, the benefits of any placebo effect are also based upon the patient's subjective assessment (conscious or unconscious) of the physician's credibility and skills.

Michael and Enid Balint together pioneered the study of the patient-physician relationship in the UK. Michael Balint's "The Doctor, His Patient and the Illness" (1957) outlined several case histories in detail and became a seminal text. Their work is continued by the Balint Society, The International Balint Federation and other national Balint societies in other countries. It is one of the most influential works on the topic of doctor-patient relationships. In addition, a Canadian physician known as Sir William Osler was known as one of the "Big Four" professors at the time that the Johns Hopkins Hospital was first founded. At the Johns Hopkins Hospital, Osler had invented the world's first medical residency system. In terms of efficacy (i.e. the outcome of treatment), the doctor–patient relationship seems to have a "small, but statistically significant impact on healthcare outcomes". However, due to a relatively small sample size and a minimally effective test, researchers concluded additional research on this topic is necessary. Recognizing that patients receive the best care when they work in partnership with doctors, the UK General Medical Council issued guidance for both of doctors named "Ethical guidance for doctors" and for patients "What to expect from your doctor" in April 2013

Physician superiority
Historically, in the paternalistic model, a physician tended to be viewed as dominant or superior to the patient due to the inherent power dynamic of physician's control over the patient's health, treatment course, and access to knowledge about their condition. In this model, physicians tended to convey only the information necessary to convince the patient of their proposed treatment course. The physician–patient relationship is also complicated by the patient's suffering (patient derives from the Latin patior, "suffer") and limited ability to relieve it without the physician's intervention, potentially resulting in a state of desperation and dependency on the physician. A physician should be aware of these disparities in order to establish a comfortable, trust-based environment and optimize communication with the patient. Additionally, it may be beneficial for the doctor–patient relationship to create a practice of shared care with increased emphasis on patient empowerment in taking a greater degree of responsibility for their care.

Patients who seek a doctor's help typically do not know or understand the medical science behind their condition, which is why they go to a doctor in the first place. A patient with no medical or scientific background may not be able to understand what is going on with their body without their doctor explaining it to them. As a result, this can be a frightening and frustrating experience, filled with a sense of powerlessness and uncertainty for the patient. An in-depth discussion of diagnosis, lab results, and treatment options and outcomes in Layman's terms that the patient can understand can be reassuring and give the patient a sense of agency over their condition. Concurrently, this type of strong communication between a doctor and their patient can strengthen the physician-patient relationship as well as promote better treatment adherence and health outcomes.

Medical mistrust
Mistrust of physicians or the healthcare system in general falls under the umbrella of medical mistrust. Medical mistrust negatively impacts the doctor-patient relationship, as a patient who has little faith in their physician is less likey to listen to their advice, follow their treatment plans, and feel comfortable disclosing information about themself. Some forms of communication by the physician, such as self-disclosure and patient-centered communication, have been shown to decrease medical mistrust in patients.

Medical mistrust has been shown to be greater for racial and/or ethnic minority patients, and is associated with decreased compliance, which can contribute to poorer health outcomes. Research of breast cancer patients showed that African American women who received concerning mammogram results were less likely to discuss this with their doctor if they had greater medical mistrust. Another study showed that women with higher physician mistrust waited longer to report symptoms to a doctor and receive a diagnosis of ovarian cancer. Two studies showed that African American patients had more medical mistrust than White patients, and were less likely to undergo a recommended surgery as a result.

Physician communication style
Physician communication style has proven to be crucial to the quality and strength of the doctor-patient relationship. Patient-centered communication, which involves asking open-ended questions, having a warm disposition, encouraging emotional expression, and demonstrating interest in the patient's life, has been shown to positively bolster the doctor-patient relationship. Additionally, this type of communication has been shown to decrease other negative attitudes or assumptions the patient might have about doctors or healthcare as a whole, and has even been shown to improve treatment compliance. Another form of communication beneficial to the patient-provider relationship is self-disclosure by the physician in particular. Historically, medical teaching institutions have discouraged physicians from disclosing personal or emotional information to patients, as neutrality and professionalism were prioritized. However, self-disclosure by physicians has been shown to increase rapport, the patient's trust, their intention to disclose information, and the patient's desire to continue with the physician. These effects were shown to be associated with empathy, which is another important dimension which is often under-emphasized in physician training.