The enigma of doctor-patient relationship

Abstract

The doctor–patient relationship is crucial to the health-care delivery. In the past, the relationship was viewed as one between a healer and a sick person. However, in the modern era, it is seen as an interaction between a care provider and a service user. The Mental Healthcare Act (MHCA) 2017 gives importance to rights and provision for more autonomy to patients. We examined, in the context of the existing literature, the potential impact the implementation of MHCA 2017 can have on the doctor–patient relationship. A bond between doctor and patient that is based on trust has been an integral part of patient care and has been described to promote recovery, reduce relapse, and enhance treatment adherence. Growing mistrust among patients toward doctors leads them to change their doctors frequently, and due to this, the patients are at risk of losing the therapeutic benefit of the doctor–patient relationship. The doctor–patient relationship has been understudied in areas of health-care need, such as in rural areas, where accessibility and availability of care itself become the most important goal. Medical advancement, with several new treatment options, as well as the availability of many experts for patients to choose from, seems a boon turning into a bane. MHCA 2017 and other health-care policies so far have not given importance to this relationship that is being damaged by several factors including rising health-care costs, especially in private sector and after patients have become “consumers.” However, for now, the foremost thing is the psychiatrists have to work to comply with the law and document to justify clinical decisions.

INTRODUCTION

The doctor–patient relationship is crucial to health care delivery. It is described differently by different disciplines such as psychology, physiology, psychotherapy, philosophy, sociology, health policymakers, and human resources.[1] This relationship, which was seen as one between a healer and a sick person more than 5000 years ago, has now evolved to be considered as one between a care provider and a service user. Compared to other disciplines in medicine, the field of mental health is unique where the care is delivered to patients who have varying degrees of awareness, beliefs, and understanding about their illness. The illness itself can affect their ability to trust, understand, or make judgments to arrive at a decision. Assertive outreach teams, such as the one as per England's mental health policy, are a useful model to ensure that the care reaches the needy.[2] In the outpatient clinic, many times, the consultations and decisions would depend on the doctor's rapport with the caring family members.[3] Under the provisions of the Mental Health Act 1987, persons thus, seen in outpatient clinic and needing inpatient care were admitted against their willingness at the request of the family or relatives.[3] The Mental Healthcare Act (MHCA) 2017 gives importance to the rights of the patients.[4] It gives directions to the psychiatrists that patients are provided more autonomy in making decisions about their care and treatment, even when family members are not agreeing to that decision. However, when the patient loses insight and loses the ability to make decisions for self, MHCA 2017 mandates use of relevant sections of the act by psychiatrists to admit and provide care and treatment against the patients’ wishes. Except in such situations, the person with mental illness chooses the care by himself/herself. This means, while adhering to MHCA 2017, a psychiatrist might have to intervene differently with the same patient in a different situation, which is based on the capacity to decide care. This varying approach can cause instability in the doctor–patient relationship. Keeping this background of varying approach to patients with mental illness and with the changing dynamics of the doctor–patient relationship, we try to explore the implications of the MHCA 2017 in practice in this article.

HISTORY OF DOCTOR–PATIENT RELATIONSHIP

Ludwig described that during Egyptian practices, between approximately 4000 BC and 1000 BC,[5] the relationship was seen as a priest–supplicant relationship, with magic and mysticism method of healing, with the priest or the healer having a parent figure.[6] Then came, in the 5^th Century BC, the Greek way of treating that was based on trial and error method, as they rejected the effects of magic. The historic Hippocratic Oath was developed by this civilization that developed a code of ethics for doctors. Magico-religious beliefs reemerged in medieval European era and negatively affected the relationship. Following the French revolution, the practice of placing persons with mental illness into dungeons stopped. From the 18^th century, there was the beginning of the concept of illness. During this time, the doctors established supremacy due to being fewer in number and as most were from the upper class. The hospitals provided care with the biomedical model of illness, and the relationship was more paternalistic “Active-Passive” type. Gradually, doctors’ role involved decision-making in the best interest of their sick patients, where the patients were liked if they agreed submissively to care.[7] However, some authors emphasized a more democratic way, arguing for cooperation than a paternalistic approach.[8]

Even in different cultures, there were common dialects to describe the subjective experiences of patient's illnesses, and the therapeutic relationship was built on concerns over health. Neki argued that in the Indian context, the traditional Guru-Chela model may be therapeutic.[9] The follower or the “Chela” is a disciple of the “Guru” formed a dependent relationship on the basis of faith, with “Guru” having responsibility to do best for “Chela.” Szasz and Hollender outlined the following three basic models of the doctor–patient relationship: (a) Active-Passive model: In case of an emergency, the doctor treats an unconscious patient as inanimate; (b) Guidance-Cooperation Model: The doctor is considered to be higher in terms of position and power due to medical knowledge and is expected to work in the patient's best interest, and the patient is expected to comply with the recommendations accordingly; and (c) Mutual Participation Model: Both the parties have equal power. The patient is considered an expert in a mutually interdependent interaction, with patient having crucial involvement in making a care plan to achieve treatment goals.[10] A doctor–patient relationship with good agreement enhances trust in the doctor.[11] The main components in the relationship are knowledge, trust, loyalty, and regard.[12]

DYNAMICS OF DOCTOR–PATIENT RELATIONSHIPS

Nature of mental health issues

Doctor–patient relationship varies depending on the type of mental illness and patients’ understanding of their problems. Patients with depressive or anxiety disorder are more likely to approach with positive attitudes toward in comparison to those with psychotic symptoms.[13] Similarly, persons with histrionic personality may exaggerate their mental illness, whereas paranoid and schizoid personalities tend to avoid or do not seek help.[14] The internalized stigma associated with mental illness can sometimes be discouraging to seek help from mental health professionals.[15]

Clinical settings

Patients can lose the trust with doctors that was developed in the outpatient clinic if patients are admitted against consent or if forceful admission is done. Patients can feel humiliated with forced admission. Furthermore, older doctors are considered experienced and generally viewed with high regards. Similarly, the clinical set-up, for example, how the outpatients’ chairs are set, whether enough opportunity is there for the patients to speak and feel listened to, will also impact on the relationship. However, if chairs are set up at the same level to sit, it gives the sense of a collaborative relationship. However, it would feel paternalistic if the doctors have big cushion and special chairs compared to those provided for the client.[13]

Doctors’ attitudes

The differing attitudes and beliefs from the different cultural background of the doctor and patient also affect the interaction. Good quality communication with patients enhances bond, promotes healing, and reduces the chances of getting involved in judicial litigation in unfortunate circumstances.[16,17] Doctors working in a highly challenging environment may experience burnout, and this again affects their way of practice and relationship with clients.[18] Showing non-judgmental, collaborative approach, and providing realistic outcome goals help in improving the doctor–patient relationship.[19,20]

Rural versus urban health care

In rural areas, poor information regarding their illness, lack of resources to gather information, and poor health literacy can prevent accessing the existing limited health care, and the issue of access to care and availability of practitioners becomes priority than the issue of likes or dislikes toward doctors.[21] Availability of many specialists in some urban areas in India could make a few patients decide to try with a new specialist, thus reducing opportunity to develop working relationship and could become a source of dissatisfaction for doctors also.

Commercial aspects

Psychiatrists provide care to all irrespective of caste, creed, religion, or financial status. However, some doctors practice in bigger hospitals more accessible to affordable class, and other physicians working in the public sector cater to poorer persons. It is likely that quality of care may differ depending on affordability, and individual experiences of relationship may vary. Unethical, corrupt practices, without providing much information about the illness and treatment options, have generally troubled the relationship in recent times.[13,22]

Attitudes of carers toward mental illness

In the Indian context, the decision of the family or more particularly the supposed head of the family can influence whether needy patients with mental illness access the care. Even though the doctor–patient relationship may have been established, the caregivers’ opinion toward certain mental illness may become a barrier to the provision of treatment. This happens possibly due to cultural beliefs or stigma, especially during the maintenance phase of treatment, and eventually leads to non-compliance to medications, relapse, and a poorer outcome. However, after coming to know about their fallacies, the family members, though they understand the need to seek consultation, may feel embarrassed, causing a further barrier to the relationship. Some carers attribute mental illness to magic or religious reasons, affecting adherence to treatment.[23]

Transference and countertransference

The understanding of clients and therapists of each other, based on their own set of feelings or attitudes, depends on their past experiences. These reactions, especially from the therapists, or the countertransference, can hinder the evaluation of the client due to the doctor not being able to understand the client further but has own presumption or prejudice that could derail the relationship. To develop a therapeutic relationship, trainee psychotherapists learn to deal with countertransference. However, these days, due to a busy schedule and limited time and resources, it is becoming hard for doctors to understand the client. This can have some serious consequences as the patient may think doctors do not understand them, and this may also be a reason for lawsuits against doctors.[24]

Doctor as healer and placebo effect

It is known that patients’ emotions and cognitions about a treatment or therapist impact the therapeutic outcomes. The term placebo in Latin means “I shall please.” During the visit to a hospital, while interacting with the doctor, several social and sensory stimuli, along with the patient's personal beliefs, old memories of having experienced the care, or hearsay, including anticipation, contribute to the patient experiencing something more than just the treatment offered.[1] Similarly, there is a term called nocebo (in Latin, meaning “I shall harm”), which can have negative consequences due to negative beliefs and attitudes. One example of nocebo effect could be when a person having fear of developing side effects of nausea, vomiting with medications can develop nausea on taking antiemetic drugs without knowledge. Trust by the patient on the physician has multidimensional aspects and depends on competency, compassion, privacy, confidentiality, reliability, dependability, and communication.[25] Thus, aspects of care in the form of compassion, support, empathy, and communication may all help in a better outcome.

Therapeutic relationship

Therapeutic interpersonal relationships are a primary component of all health care interactions that facilitate positive clinician–patient experiences.[26] Consequently, with an increasing patient-centered care approach, it is imperative for health care professionals to therapeutically engage with patients to improve health-related outcomes.[26] Carl Rogers's client-centered theory describes empathy, genuineness, unconditional regard, respect, and warmth as crucial elements for good therapeutic efficacy. In a study by Sutherland et al., 63% of patients with cancer expressed that the physician should take the primary responsibility in decision-making, 27% felt it should be equal, and 10% wanted they themselves should take a major role.[27] In another study, patient satisfaction was associated with the doctor's emotional response, including non-verbal communication, showing more interest, and making eye contact.[28] Some of the “positive psychiatry” approach that are routinely practiced are creation of optimism, setting goals, encouraging the patient to modify their lifestyle, non-biased approach, and a non-judgmental approach incorporated in empathic interviewing.[29] These types of approaches help in recovery, patient satisfaction, and adherence to treatment.[26] The therapeutic alliance is not only dependent on an agreement over goals and tasks involved in treatment but also on the personal bond between the doctor and the patient.[30] McCabe et al. found that improved therapeutic relationship enhances medication adherence in patients with schizophrenia, thus playing a role in improved outcomes, reduced dropouts, and less number of hospital admissions.[31,32]

CONTEMPORARY DOCTOR–PATIENT RELATIONSHIP

Doctor–patient relationship has been changing rapidly in this era of technological revolution. Patients, at home, can browse through a plethora of information about their condition and their available treatment. This means they now have a unique tool which when used appropriately can immensely benefit the patient and the doctor. However, as with new technology, changing culture and the shift toward more individualism and autonomy have made this information tool a double-edged sword. Internet sources of information can lead to patients’ questioning the doctor's expertise and knowledge in terms of mental health and in turn, leading to conflicts in the relationship.[33] With this, physicians may get confused whether to debate regarding the understanding that patient has or to focus on rapport building for better treatment outcomes. The other possibility is the patient may decide to seek consultation with a second and subsequently a third doctor, thus losing out on the therapeutic benefit in the relationship. The courts expect the doctors to provide only a reasonable degree of care.[34] They have to bring in a reasonable level of knowledge and competence to exercise a reasonable degree of care, and the doctor does not have to ensure every person is cured.[34]

IMPACT OF MHCA 2017 ON DOCTOR–PATIENT RELATIONSHIP

Under MHCA 2017, the patients have the right to clarify the evidence-base of the offered treatment, based on their sources of information or interpretation. Sometimes, it may be worth seeking a second opinion from colleagues or referring to another center if a particular health issue is not in the area of the doctor's expertise. There will also be areas of disagreements over the decision with clients or family members. For example, the patients do not want admission but are at high risk of harm to self/others due to the intensity of mental illness and in reality needs detention. Similarly, when the patient is unwell and the risks cannot be identified during the assessment, but the family wants admission and the patient is not willing, then continue treatment as per the patient's wishes in the community. This means in the first scenario, the patient is not happy, and in the second, the family members are not happy. Therefore, it is worth remembering that there are chances of making one of the parties unhappy while executing duties in compliance with the act. A peer group of doctors, with the help of legal advice, will have to find avenues to overcome this problem and to make both the patient and the family satisfied. Detention through the MHCA 2017, after offering admission as independent patient, and patients appealing against their detention, and the same psychiatrist continuing to treat at the time of discharge, can have an impact on the mental health care in general.

Documentation becomes an integral part and should include the basis for reaching a particular decision. Therefore, the psychiatrist, instead of taking the role of a healer or therapist, might have to work defensively to justify the decisions made and always anticipate being questioned for a particular decision and for not taking an alternative decision. In the process, the time spent in having a dialogue with a patient could get reduced compared with the time spent in filling forms, documentation, ensuring that the medical notes are in order, repeatedly examining whether the care they provide is in compliance with MHCA 2017. Patients can also be in a state of ambivalence to appeal against detention under a psychiatrist they have clinical relations with. Treatment disengagement by patients having a severe degree of mental illness leads to a risk of dropouts and rehospitalization.[35] When a patient with severe mental illness opts to not accept treatment, the psychiatrist may have to frequently review for likelihood of patient's condition getting worse as a result and person also losing capacity, then it may be possible to initiate involuntary treatment. However, the psychiatrist may again become helpless if, after subsequent improvement, the patient again refuses to accept further treatment. Patient has no obligation to involve family members and doctors in deciding their care and could decide to disengage from services. In other words, the act has not taken into account the preventive measures for “revolving door” kind of admissions. Sometimes, repeated relapses could lead to worsening of the course of the illness and increased disability. Then, such patients may have to be cared for by the state by providing rehabilitation care. Furthermore, a good therapeutic relationship with patients with suicide attempt will minimize the chance of further attempts.[36] However, the beneficial effects of therapeutic alliance seem to have not received its due attention while framing the MHCA 2017.

Consumer Protection Act of 1986 came into effect in mid-April 1987. It was intended to safeguard the interests of the consumers and assist settlement of disputes under the framework of this law.[37] Supreme Court, through its landmark judgment in the case “Indian Medical Association vs. VP Shantha,” in 1996, brought medical practice under Section 2(1) (0) of the Consumer Protection Act.[38] A doctor has certain duties toward ailing patients who seek consultation. A significant deficiency in the care provided may constitute medical negligence. Risk of litigation and seeking of compensation through Redressal Committee have possibly contributed to making medical practice more defensive.[34] In India, health care is predominantly catered by the private sector.[39] Although the court interprets the constitution of India's Article 21 as the right to health, only a small proportion of health care is provided by the state.[40] The Consumer Protection Act already has put barriers to developing a doctor–patient relationship, as patients and relatives look at doctors suspiciously, in turn, making doctors more defensive. It appears that doctors are being made to work under an umbrella of fear, which may impact on their confidence to treat, which is not going to help patients.

TRUST IN DOCTOR-PATIENT RELATIONSHIP

Trust is an integral part of any interpersonal relationships and has beneficial effects on treatment outcomes.[25] Some scientists have studied biology, where they found that trust behavior undergoes modulation by oxytocin enhancing social cognition and helping in better engagement.[1] There has to be reciprocity in terms of trust, and both parties have to develop professional ties with honesty and respect.[41] There is a need to focus on one goal of improving the health of the patient to be achieved from the relationship.[42] Growing complaints, threats of complaints, abuse, and litigation can make doctors apprehensively assuming every patient is a potential litigant, and this kind of environment could further damage the trust the doctors have on patients, would be detrimental to the treatment outcomes, and overall impacts negatively on satisfaction over the health care system. With the growing technology, smartphones or smart devices can be used to record the consultation with the doctor. If the patient and relatives want to record the conversation, then the doctor, in defense, has to a work way out to prevent potential problems from this discussion, which the doctor was never trained for or used to in clinical practice before. Gradually, this would lead to patient and doctor exchanging information that would be completely recorded, which would demonstrate the declining trust between both doctor and patient. All physicians will then have a duty to prioritize their own health and avoid getting into a stressful situation.[43]

CHANGES NEEDED IN INTERVIEWING SKILLS

The art of interviewing involves rapport building. Rapport establishment may not occur in the first visit, and therefore, the patient may not engage. Decision-making, after gathering evidence to rule out risks, to ascertain the need to comply with MHCA 2017, becomes a priority, and therefore collateral information will be sought. A patient experiencing persecutory ideas may question the doctor's intention, then the doctor would find it difficult to justify and convince the patient. This poor rapport may delay commencement of treatment because then, one has to wait until the patient is deemed to be incapacitous to receive treatment and also the clause of a risk of harm to others or self has to be satisfied. This is when relevant section 89 or emergency section 94 can be applied. Applying these sections will further worsen the rapport building, and overall, the doctor–patient relationship may get hampered, which later have to be rebuilt. MHCA 2017 seems to have ignored the rapport building part, which is a basic need for developing trust for favorable treatment outcomes. There cannot be paternalistic kind of interviewing, but more interactive type, but in the end, psychiatrists are expected to provide options of care available. Despite contrasting views by the family members, more weightage has to be given to the views of the patient, except in situations where evidence of an increasing risk of danger to self or others is established. Even when the patient is deemed to be incapacitous, to decide about treatment, the psychiatrist has to find the least restrictive approach. Interviews will have to be directed toward providing information in the way the person can understand. Furthermore, the doctor will have to focus on gathering evidence to ascertain the magnitude of risk of harm to self or others.

CONCLUSION

Historically, doctors began with privilege that people offered them for treating an ailing person. With the field of medicine growing to the modern era, commercialization and consumerism gave rise to an unhappy patient population, especially over rising costs of care. They began to express mistrust over the physicians’ agenda. Trust between doctor and patient started to diminish as doctors started worrying about potential litigation from consultations. A basic provision of health care with doctor being available itself becomes priority in the areas of health care need such as some of the rural areas in India. More physicians concentrating in urban areas and the easy options to change the physician may also make the patients putting less effort into developing a relationship. The contemporary doctor–patient consultation seems to have become such that there is an aim to manage the patient, using policies and legislation, without a need to build a therapeutic relationship. These further lead to growing dissatisfaction among the consumer patients and, in turn, make doctors unhappy. The article discussed the therapy aspect in the trusting, strong alliance between doctor and patient, which should be the priority in terms of health and well-being of the patient. The damage that has occurred in the doctor–patient relationship has affected health care provision. In general, complying with the law and improved documentation to justify the decision has become essential.

Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.