LETTER TO THE EDITOR

To the Editor:—I would like to congratulate Dr. Adler¹ for his insights regarding the doctor-patient relationship, one of the new challenges of the 21st century.

For busy practitioners, there is the convergence of the physiology of stress and our ability to be compassionate healers. If we allow our emotions to interfere with our trade knowledge, we become less effective physicians. At the same time, we must deal with our emotions in the establishment of a caring relationship with a compassionate bedside manner. We need to maintain professional distance and at the same time bond with the patient, therefore reducing both the patient's and the physician's stress.

How do we learn to deal with our emotions in order to avoid our own burnout? Does the patient perceive that the doctor is listening? We are not taught in medical school how to be prepared for the emotional stress we feel in caring for the sick patient. We learn of individual disease but not of patients with illnesses.

In the psychosomatic patient, we are taught not to order unnecessary studies but to listen and spend time with the patient. Do these patients then move on with their lives knowing that they do not have a serious medical problem, or are they dissatisfied because the MRI was not ordered?

When patients die, is our role as physicians over? Do we have responsibilities to the surviving family? Do we recognize our own emotions, including failure and self-doubt, and should we communicate those to the family? Do we write a letter of condolence to the patient's family, and how close should we be to the patient's family during the bereavement?

Burnout syndrome occurs when physicians are unable to handle negative stress when treating patients. This can occur with the steady stream of patients seen in the emergency room, the oncologist's office, or even with the psychiatrist dealing with mental illness and suicide.

People want doctors to take care of them like parents. Doctors have reactions to patients due to their own personalities, and the chemistry may not always be perceived as one of caring.

In the managed-care environment, physicians perceive that they have lost autonomy. Stressors include sentinel events, malpractice lawsuits, federal and state regulatory and compliance programs, fear of audits, and medical error reporting.

What is the reaction of physicians to treatment plans with unfavorable outcomes? Is that expected as part of the illness, or does the physician question his own judgement?

In the evaluation of patients with pain and other ill-defined syndromes, e.g., fibromyalgia, what is the response to treatment, what is the expectation of the patient and the physician to treatment?

Patients have higher expectations with new information and technology. They search the Net, making their own diagnoses and questioning treatment programs. Does the physician feel the patient's knowledge to be threatening or enlightening?

Physicians have hardships related to lower economic reimbursement. There are increased costs and pressures placed upon the physician running a practice. In the context of lowered reimbursement, how does the physician place a value on the quality of service he provides, as opposed to cost savings? There are new quality indicators, patient satisfaction surveys, practice guidelines, and outcome studies that extend beyond the individual doctor-patient relationship.

What do we define as quality service? It is now felt that quality can be measured. Physicians derive satisfaction when their recommendations are followed through by the patient and are frustrated when patients do not wish to comply.

New research is needed for patients who are considered to be high risk—those who are dying (as part of hospice programs), those with post-traumatic stress disorder, the elderly, and children.

Medicine has survived other periods of crisis. The doctor-patient relationship has prevailed. In the face of economic, political, and social threats to both physicians and patients, it is imperative that doctors continue to recognize their own feelings so as to provide high-quality medical care to their patients. Dr. Adler's article is inspirational for all those physicians who continue to practice medicine. As we become more aware of our feelings and experiences, both the patient and physician will derive strength.