The doctor-patient relationship has never fully recovered from Freud. Before the advent of psychoanalysis, patients went to doctors, who administered a treatment—perhaps a tablet or a procedure. The relationship between physicians and client was not the primary issue; it was merely a mechanism that facilitated delivery of the treatment. After the Freudian revolution, the relationship between doctor and patient could itself become the prescription.
TIM SANDERS.
Is it now a doctor's remit to provide the kind of positive supportive relationship that is difficult to find elsewhere? Even if doctors were willing to shoulder this project, the public should beware. Harold Shipman was, after all, by many accounts, popular with his patients.
In Freudian analysis much of the work of the “doctor” is to think hard and analyse the nature of the relationship that develops with the client. The doctor even has to relentlessly question his or her personal emotional reaction to the patient, and analyse that, partly to ensure the doctor-patient relationship can survive the physician's own neuroses. This relationship thing is getting complicated.
The latest data find that those doctors who emotionally care most for their patients are also most likely to become “burnt out” and have severe psychological dysfunction as result. A fifth of young doctors display prominent mental health problems. The doctors who emotionally cared least for patients seemed most resilient to the stress of seeing them, according to some recent research.
Doctors themselves rate about 15% of all patient encounters in primary care as “difficult” from an emotional standpoint. A recent survey of 200 British general practitioners conducted by the market research company NOP for Reader's Digest magazine found that half say that what they really want to tell their patients is that they should wash before coming to see them. Half of them also wish they could say to patients, “You say you've taken your medication, but I don't believe you.”
Common requests from doctors for their patients include: “Please don't answer your mobile phone while I am giving you a smear test.” Two thirds want to tell their patients they are too fat, but the doctors are so frustrated with being treated like “super-market assistants” that they are usually unable to hint at what they really think of their patients.
Patients, on the other hand, are described in qualitative studies as having to work extremely hard to get doctors to take their suffering seriously. It looks as though things are getting so bad in the doctor-patient relationship that divorce might emotionally be on the cards.
The latest model for the consultation is “evidence based patient choice,” the central principle of which is that doctors should become more “patient centred.” Here the conventional medical appointment is transformed to provide patients with evidence based information in a way that facilitates their ability to make choices or decisions about their health care. The model emphasises respect for patients' preferences and their involvement in healthcare decisions, and advocates the sharing of medical information rather than the more traditional role of guidance by the doctor—a reflection of the supposed imbalance in expertise and experience of doctors and patients. It's all about “empowering” patients.
Yet medical education still tends to put the disease, rather than the patient, at the centre of what doctors' work is primarily about. Despite surveys finding that the average doctor spends at least half his or her working day talking to patients, the relationship with patients still occupies a relatively marginal place in medical training compared with the biological study of pathology. Changes are only now being considered, mainly because the rise of the internet and other information technologies means that many patients now can feel as informed as doctors—though the information is often of dubious quality.
It seems that doctors need a mechanism for uncovering what particular kind of relationship a patient might require during a particular consultation, but to baldly inquire after this seems to render the encounter awkward and mechanistic.
Perhaps both doctors and patients need to become more aware that each side probably has a repertoire of relationships they are capable of, just as we are all able to have a different association with our grandmothers than with our girlfriends. Maybe then both can learn to constantly but subtly negotiate what kind of alliance is best suited to them. After all, this delicate dance is precisely what happens at the start of most intimate relationships and is never an entirely unproblematic choreography. This explains widespread relationship phenomena, like heartbreak and stalking.
At the heart of strong associations is each party having a good sense of how the other feels—or empathy. It is notable that a substantial number of doctors aren't themselves registered as patients with general practitioners. Perhaps one of the most profound element of a doctor's education is to feel what it is like to be a patient. This brings us back full circle to the Freudian idea that all clinicians should have their own analyst, a notion that perhaps was abandoned too soon.
If doctors and patients are to enjoy a second honeymoon, both sides need to realise the mutual benefits of the hard work it takes to keep the relationship going.
Competing interests: None declared.