Treating The Ailing Doctor-Patient Relationship

The practice of medicine is probably almost as old as the human race. An important part of the Shaman's job was the diagnosis and treatment of the physical and mental symptoms afflicting sick members of the tribe. Ever since, doctors have been admired and well rewarded despite the fact that few of their remedies actually worked and many were actually quite dangerous (eg, bleeding, cathartics, inducing vomiting or fevers, heavy metals, and it goes on and on).

It was the power of the doctor-patient relationship that made patients feel better. It offered an explanation (however false), hope, placebo effect, support, and time and space for natural healing

In recent decades, modern medicine has improved the technical efficacy of many treatments, but has degraded the importance of the doctor-patient relationship. Doctors now have too little time and too many patients; too much focus on the lab results and too little on the person; and too much reliance on hyped medical magic, too little on Hippocratic human caring 

I am delighted to introduce the work of Andreas Vilhelmsson, PhD, from the Faculty of Medicine, Lund University, Sweden. Dr Vilhelmsson has conducted a fascinating study of consumer attitudes towards doctors among patients receiving antidepressants. His conclusions help us understand what goes wrong in the doctor-patient relationship and suggests steps needed to fix it.

Dr Vilhelmsson writes:

"Beginning in the 1960s, the patients’ rights movement questioned traditional authoritarian doctor-patient communication because it neglected patients’ beliefs, priorities, and concerns. Together with the growth of consumerism and expectations of individual responsibility, this advocacy led to the widespread sense that healthcare would become more patient-oriented.

However, our study of consumer experiences showed that this is often not the case. Patients report frequent negative interactions wth doctors that impact negatively on the diagnosis and treatment of depression.

Doctors and patients quite often had very different accounts of the nature of the problems for which the patient was seeking help. Patients often seek help for physical problems such as tiredness and sleeplessness, but felt the doctor rushed to a depression diagnosis, without listening to what they felt had caused their problems-- especially stresses or losses in work or interpersonal life situations.

When patients protested against a medical model understanding of their problem, doctors persisted in stressing it. Patients reported not having the strength to argue with their doctor’s decisions and instead agreed on the depression diagnosis, despite really believing they were exhausted, not depressed.

Patients felt that antidepressants were prescribed without the doctor asking for or listening to their story. Antidepressant drugs might be offered during the first consultation, and sometimes even in the beginning of this meeting. Sometimes, doctors used an analogy of a chemical imbalance in order to describe the need for antidepressant treatment and stated that pills might be necessary for life. In one case, antidepressant drugs were even compared to vitamin pills, as something the patient should understand as a 'vitamin boost.'

Some patients reported that it felt like antidepressant medication was all the doctors had to offer, that no alternatives were presented to them. Either they took the pills offered or there was nothing the doctor could do. Several patients wanting 'someone to talk to' reported being reluctant to use antidepressant treatment, and many felt forced to follow the doctor’s wishes. There were even reports of doctors threatening their patients they would not initiate or would withdraw their sick-listing unless they agreed to antidepressant treatment.

Psychotherapy was seldom presented as a valid treatment option and a few patients reported having to contact private caregivers just to be certain they would get the treatment they wanted. Those patients who were offered psychotherapy often reported being more satisfied.

There were also differences of opinion in explaining emerging symptoms. Patients almost always interpreted negative experiences as due to the drug while the doctor construed them as evidence of the initial depression recurring. This was especially present during discontinuation.

Some patients referred to losing trust in their doctor when they perceived that he did not care about them as people. Trust was sometimes compromised as early as in the first consultation. Some patients complained of arrogance and an unsympathetic attitude from the doctor and some even felt abandoned with a lack of follow-ups and prescriptions being renewed without personal contact.

All and all, these consumer experiences correspond poorly with a patient-oriented health care. But there is no point in blaming only the doctors. The medical encounter takes place within a system where diagnostic handbooks and short form tests are used as a fast way to judge a patient’s health status and to reach a diagnosis -- without a comprehensive investigation of the whole situation surrounding the patient.

This seriously compromises good treatment. Inaccurate diagnoses can lead to inappropriate patient care, poor patient outcomes, increased costs, and an overall diminished trust in the health system."

Thanks so much, Dr Vilhelmsson for describing the kinds of things that can go wrong in the doctor-patient relationship. It is easy to have misunderstandings, hard to have clear communication. What can be done to get it right?

1. It takes time to hear the patient out so as to arrive at an accurate diagnosis and a negotiated, mutually agreed upon treatment plan. This means time in each visit and often multiple visits. Insurance companies force a rush to judgment despite the fact that the extra time spent on accurate diagnosis and a nurturing doctor-patient relationship is quite cost effective in the long run. Unfortunately, the average primary care physician spends fewer than 10 minutes with a patient and makes a diagnosis on the first visit-- often prescribing an unnecessary and expensive long term medication treatment that would be avoidable if he heard the patient out and applied watchful waiting rather than a rush to judgement.

2. Severe depression is a medical emergency that requires immediate diagnosis and treatment - but most mild psychiatric symptoms get better with time, hope, reliance, reduced stress, and support. Medication should be started immediately with severe depressions, but be only a last resort in mild ones. 

3. Patients should be full partners in decision-making. The pluses and minuses of each option should be explained and in most instances the patient should have the final call.

4. Psychotherapy is at least as effective as medication for milder symptoms and is greatly underutilized. Because of time constraints and misleading drug company marketing, medication is greatly overutilized.

 Hippocrates said: "it is more important to know the patient who has the disease than the disease the patient has." This remains true after 2500 years and with all the hype of modern medicine. The availabilty of effective treatments is wonderful, but should supplement not replace the magic of a healing doctor-patient relationship.