Clinician–Patient Relationship

The physician–patient relationship is an important component of health care delivery. (The terms physician and clinician will be used interchangeably here, acknowledging that other clinicians have similar relationships with patients and are bound by the same code of ethics Ethics Medical ethics are a set of moral values that guide the decision-making of health care professionals in their daily practice. A sense of ethical responsibility has accompanied the profession of medicine since antiquity, and the Hippocratic oath was the 1st document to codify its core ethical principles. Basics of Medical Ethics.) Except in emergencies, before a clinician can initiate a medical or surgical intervention with a patient, a relationship of trust and empathy must exist, allowing the patient to talk about their medical issues. The clinician–patient relationship is a bond that, in many cases, requires some cultivation and may ultimately result in better outcomes. In the United States, the American Medical Association publishes a code of ethics Ethics Medical ethics are a set of moral values that guide the decision-making of health care professionals in their daily practice. A sense of ethical responsibility has accompanied the profession of medicine since antiquity, and the Hippocratic oath was the 1st document to codify its core ethical principles. Basics of Medical Ethics that details the principles physicians must adhere to in providing medical care; these standards of conduct extend to the physician–patient relationship.

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Editorial responsibility: Stanley Oiseth, Lindsay Jones, Evelin Maza

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Overview

Definitions

  • Relationship: a connection, association, or involvement between 2 or more parties
  • Physician: a licensed medical doctor 
  • Clinician: a physician, nurse practitioner, physician assistant, or another health professional who is directly involved in patient care and has a professional relationship with patients.
  • Patient: a person receiving medical care 
  • Fiduciary: a person to whom power is entrusted for the benefit of another in situations in which an individual lacks decision-making capacity Decision-making capacity Decision-making capacity describes a patient's ability to make autonomous decisions regarding their care, as determined by a physician. Decision-making Capacity and Legal Competence regarding their care.

Characteristics of a clinician–patient relationship

  • Empathy: the psychological identification with or vicarious experiencing of the feelings, thoughts, or attitudes of another person; considered a quintessential virtue of a physician
  • Compassion: a feeling of sympathy or sorrow for another, accompanied by a strong desire to alleviate their suffering
  • Humanizing: The patient is understood to be a human being in distress due to the disease process. 
    • Describe patients as people, not medical conditions. Example: “Mr. M. is the patient with appendicitis Appendicitis Appendicitis is the acute inflammation of the vermiform appendix and the most common abdominal surgical emergency globally. The condition has a lifetime risk of 8%. Characteristic features include periumbilical abdominal pain that migrates to the right lower quadrant, fever, anorexia, nausea, and vomiting. Appendicitis in room 12,” not “That’s the appendix that just came in.” 
    • Use nonstigmatizing and patient-focused language. Examples: “people who use injection drugs,” not “IV drug users,” and “patient-directed discharge” versus leaving “against medical advice.”
  • Confidence and trust: Physicians communicate that they are professional and trustworthy and will listen to and address the patient’s complaints. 
    • Verbal cues: attentiveness to and genuine interest in the patient’s recollection of their medical history
    • Nonverbal cues: professional conduct and appearance 
  • Reassurance: the patient’s emotions, feelings, and concerns are validated and addressed.
  • Mutual consent: certain circumstances may create a limited relationship without the patient’s explicit agreement:
    • Emergency care: the patient’s agreement to the relationship is implicit.
    • Court-ordered medical care for a prisoner: in keeping with ethics Ethics Medical ethics are a set of moral values that guide the decision-making of health care professionals in their daily practice. A sense of ethical responsibility has accompanied the profession of medicine since antiquity, and the Hippocratic oath was the 1st document to codify its core ethical principles. Basics of Medical Ethics guidance on court-initiated treatment

Beginning and ending relationships

  • Beginning a clinician–patient relationship requires 2 elements:
    • A patient who requests the aid of a clinician.
    • A clinician who accepts the patient’s request to provide care.
  • The relationship can be ended by the physician or the patient when:
    • The former chooses not to provide care, except for vital emergencies.
    • The patient chooses not to be under the care of that physician.
    • Termination of a clinician–patient relationship by the clinician must be made via written communication with a reasonable amount of notice (typically 30 days).

Physician Responsibilities and Rights

The duties of a physician in the clinician–patient relationship go hand Hand The hand constitutes the distal part of the upper limb and provides the fine, precise movements needed in activities of daily living. It consists of 5 metacarpal bones and 14 phalanges, as well as numerous muscles innervated by the median and ulnar nerves. Hand in hand Hand The hand constitutes the distal part of the upper limb and provides the fine, precise movements needed in activities of daily living. It consists of 5 metacarpal bones and 14 phalanges, as well as numerous muscles innervated by the median and ulnar nerves. Hand with the code of ethics Ethics Medical ethics are a set of moral values that guide the decision-making of health care professionals in their daily practice. A sense of ethical responsibility has accompanied the profession of medicine since antiquity, and the Hippocratic oath was the 1st document to codify its core ethical principles. Basics of Medical Ethics.

Clinician’s responsibility

  • To provide competent medical care 
  • To follow the basic principles of medical ethics Medical Ethics Medical ethics are a set of moral values that guide the decision-making of health care professionals in their daily practice. A sense of ethical responsibility has accompanied the profession of medicine since antiquity, and the Hippocratic oath was the 1st document to codify its core ethical principles. Basics of Medical Ethics: beneficence, nonmaleficence, autonomy, and justice 
  • To act in the patient’s best interests, using medical knowledge and expertise to resolve a patient’s symptoms or providing a solution that helps achieve the greatest quality of life in a particular situation (including near the end of life)
  • To protect the patient’s privacy by keeping all information confidential
  • To disclose information to the parties involved when necessary, including bad news
  • To obtain informed consent for all procedures
  • To avoid conflicts of interest that may compromise the patient’s well-being and outcomes 
  • To respect all decisions made by a competent patient or their fiduciary
  • To represent the interests of the sick and injured against societal demands
  • To honor advance directives Advance Directives The term advance directive (AD) refers to treatment preferences and/or the designation of a surrogate decision-maker in the event that a person becomes unable to make medical decisions on their own behalf. Advance directives represent the ethical principle of autonomy and may take the form of a living will, health care proxy, durable power of attorney for health care (DPAHC), and/or a physician's order for life-sustaining treatment (POLST). Advance Directives of the patient

Clinicians’ rights

  • To refuse to provide care
  • To be treated with respect as a professional
  • To be granted the professional freedom to care for patients without interference, using their experience and the best evidence available
  • To exercise professional judgment and discretion
  • To have the independence to represent and defend the health needs of patients against all who might deny or restrict access
  • To be compensated fully and fairly for their services

Patient Rights and Responsibilities

Patient rights are a subset of human rights. They include minimum standards for the ways patients can expect to be treated by clinicians, and behind each is an ethical principle.

Patients’ rights

  • To courtesy, respect, dignity, and timely, responsive attention to their needs
  • To receive information from their physicians and have an opportunity to discuss the benefits, risks, and costs of appropriate treatment alternatives
  • To ask questions about their health status or recommended treatment when they do not fully understand what has been described and to have their questions answered
  • To make decisions about the care the physician recommends and to have those decisions respected 
  • To have the physician and other staff respect the patient’s privacy and confidentiality Confidentiality Confidentiality is a set of rules that dictates the protection of health information shared by a patient with a physician. In general, this information should only be used to dictate medical decision-making steps and can only be disclosed to a 3rd party with the patient's express consent. Patient-Doctor Confidentiality
  • To obtain copies or summaries of their medical records
  • To obtain a second opinion
  • To be advised of any conflicts of interest their physician may have with respect to their care
  • To continuity of care

Patients’ responsibilities

  • To provide physicians with a complete and truthful medical history, including past illnesses, medications, hospitalization, family history of illness, and other matters relating to present health
  • To cooperate with agreed-on treatment plans
  • To meet their financial responsibilities for medical care or discuss financial hardships with their physician
  • To recognize that a healthy lifestyle can often prevent or mitigate illness and take responsibility to follow preventive measures and adopt healthy behaviors
  • To refrain from placing others at an unreasonable risk of contracting an illness, infectious or otherwise
  • To refrain from being disruptive in the clinical setting
  • To not initiate or participate in medical fraud (e.g., falsification of medical records)
  • To report illegal or unethical behavior by health care professionals
  • To provide the physician with advance directives Advance Directives The term advance directive (AD) refers to treatment preferences and/or the designation of a surrogate decision-maker in the event that a person becomes unable to make medical decisions on their own behalf. Advance directives represent the ethical principle of autonomy and may take the form of a living will, health care proxy, durable power of attorney for health care (DPAHC), and/or a physician's order for life-sustaining treatment (POLST). Advance Directives that represent their wishes with regard to their death

Obstacles

There may be obstacles to a good clinician–patient relationship that are difficult to overcome or beyond the control of the parties involved. Identifying these is the first step to overcoming them.

Obstacles related to the physician

  • Long working hours, job-related stress
  • Compassion fatigue
  • Excessive reliance on technological advances and computerization
  • Secondary interests not in benefit to the patient (e.g., financial or research-related motives)
  • Lack of cultural competency/training

Obstacles related to the patient

  • Mistrust, dishonesty 
  • Noncompliance and nonadherence to treatment plans
  • Disrespect and mistreatment of clinicians and other members of the health care team
  • Not being forthcoming about lack of comprehension due to language barrier or level of education

Obstacles related to the medical institution and health care system

  • For-profit model of health care
  • Reduced patient choices regarding institutions and professionals

Special Circumstances

Sexual relationships

  • Between a physician and a patient are considered unethical
  • Can place the patient or the physician in a vulnerable position
  • Can impair the clinician’s ability to make objective decisions
  • Contact that could lead to an intimate relationship or that could be misinterpreted by a patient as such can be avoided by:
    • Having a chaperone/staff member who is the same sex as the patient present during the physical examination
    • Terminating the clinician–patient relationship if a patient’s behavior compromises the integrity of the physician’s practice of their profession (e.g., improper or lewd comments, flirting, explicit sexual advances) 
  • The doctor–patient relationship must be terminated before a romantic relationship can be initiated.

Family ties to patients

  • Clinicians should avoid professional relationships with their family members, since objective decision-making may be compromised.
  • Care of a family member or close friends should be relinquished to a colleague.

Receiving gifts

  • A gift is an expression of gratitude by the patient, usually given after care has been provided. 
  • The physician needs to be sensible and accepting of cultural practices while being mindful of the proportionality of the gift. 
  • A clinician must not accept a gift if:
    • It is disproportionately large.
    • The physician feels uncomfortable receiving the gift.
    • The gift signifies a significant financial burden for the patient and/or their family.
  • When a gift cannot be accepted, the physician must politely explain the reason.
  • Examples of acceptable gifts:
    • Mementos made by patients (e.g., drawings made by a patient’s children)
    • Sweets (e.g., boxes of cookies, gift baskets)
    • Culturally significant gestures (e.g., Indigenous populations in Venezuela make decorative, colorful braiding to attach to the tubing of rural physicians’ stethoscopes as an expression of their gratitude.)
  • Examples of unacceptable gifts:
    • Large sums of money
    • Properties 
    • Cars/other vehicles

Funerals

  • Appropriateness depends on the cultural context.
  • A physician may choose to attend a patient’s funeral as a guest to provide comfort to the family.

References

  1. Noseworthy, J. (2019). The future of care — preserving the patient–physician relationship. New England Journal of Medicine 381:2265–2269. https://doi.org/10.1056/NEJMsr1912662 
  2. American Medical Association (AMA). (n.a.) Patient rights. Retrieved October 23, 2021, from https://www.ama-assn.org/delivering-care/ethics/patient-rights 
  3. American Medical Association. (2016). AMA code of medical ethics. Retrieved October 23, 2021, from https://www.ama-assn.org/sites/ama-assn.org/files/corp/media-browser/principles-of-medical-ethics.pdf
  4. Baron, R. J., Berinsky, A. J. (2019). Mistrust in science — a threat to the patient–physician relationship. New England Journal of Medicine 381:182–185. https://doi.org/10.1056/NEJMms1813043 
  5. Delbanco, T., Gertels, M. (2020). A patient-centered view of the clinician-patient relationship. UpToDate. Retrieved November 9, 2021, from https://www.uptodate.com/contents/a-patient-centered-view-of-the-clinician-patient-relationship

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