Abstract
It is perhaps most useful to approach the Doctor-Patient relationship (DPR) by admitting that it’s complicated. We review some of the strategies that have been employed to mitigate this complexity, zeroing in on one that promises to capture the main features of the DPR without eliminating some of its more important, existential components; pieces of the puzzle that must be retained if we are to avoid oversimplification and the errors that can arise by ignoring important foundational properties. We believe that a useful way to look at the DPR and to capture essential features that must be balanced in the process is provided by Partnership Theory and its definition in terms of the so-called domination and partnership systems. We apply this theory to the DPR and investigate the implications of this application to health care. We see that in the absence of mitigating circumstances, adoption of the patient-as-partner model serves healthcare well and is flexible enough to accommodate circumstances that dictate modifications.
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Notes
Outside influences on the DPR include, but are not limited to:
Consumer advocacy groups; lobbyists; detailers—these groups exist in order to steer the DPR in certain directions.
Politics—funding/priorities for research; wearing a mask; getting vaccinated.
NIH—what gets funded for research.
PhaRMA—what drugs and medical devices get developed and submitted for approval; once approved, direct-to-consumer advertising (ask your doctor about XXXX).
FDA (Drugs and devices)—what gets approved for use.
CDC—guidelines for distribution/use of approved drugs/devices.
Insurance companies—what drugs/devices will be covered; copay amounts.
Media (including social media).
Family—family and friends strongly influence the developing world view, including one’s position on the dominance/partnership axis.
Cultural norms—factors like universal coverage impinge on what may be possible within the DPR.
Religion—limits on stem cell research; anti-vaxers, refusal of blood transfusions.
Several versions of the Hippocratic oath have evolved over the years. We quote from the 1994 version written by Louis Lasagna, Academic Dean of the School of Medicine at Tufts University, that has been widely accepted and is still in use today by many US medical schools. We focus on two of the items:
I will remember that there is art to medicine as well as science, and that warmth, sympathy, and understanding may outweigh the surgeon's knife or the chemist's drug;
and.
I will remember that I do not treat a fever chart, a cancerous growth, but a sick human being, whose illness may affect the person's family and economic stability. My responsibility includes these related problems if I am to care adequately for the sick.
These items explicitly, and forcefully, state that the physician must consider not only the whole patient, but others who may be affected by the problem as well.
In a similar vein, compassion is explicitly included in the AMA’s Principles of Medical Ethics with item one stating: A physician shall be dedicated to providing competent medical care with compassion.
Informed consent is usually defined as a process of communication between you and your health care provider that precedes your agreement or permission for care, treatment, or services. Every patient has the right to get information and ask questions before procedures and treatments. If adult patients are mentally able to make their own decisions, medical care cannot begin unless they give informed consent.
The informed consent process makes sure that your health care provider has given you information about your condition along with risks and benefits of the available testing and treatment options before you decide what to do.
One way to think about the complexity of the DPR is to note that communication between the parties will generally involve all of the modes of discourse available to human intercalators. Those who think about such things have identified four overarching modes: Description, Narration, Argumentation, and Exposition [14]. The typical DPR encounter will employ all four in order to properly frame the problem(s) needing solution.
Description—the patient describes the problem. For example, a patient with pain may select appropriate pain descriptors from the McGill Pain Inventory. The physician may describe the procedures involved in performing a colonoscopy.
Narration—the patient details the context within which the problem arose. This narrative is viewed by many physicians as a critically important guide to appropriate treatment and has even given rise to a new paradigm of healthcare, called narrative medicine [10]. It is of special interest to us in that its use is a potent source of empathy.
Argumentation—the physician tries to convince a patient to quit smoking; or to get vaccinated.
Exposition—this is an “umbrella” category, meant to capture whatever may have been missed by the previous three nodes of discourse. Examples include definition and exemplification (illustration). The physician will often be asked to explain certain terms, concepts, or ideas, etc. Such explanations often use examples to highlight or explain important points. The patient might ask, “What is a virus?” Part of the explanation may point to polio as an example of a disease caused by a virus. The Salk polio vaccine might be cited as the solution to the problem caused by the virus.
The Belmont Report, published in 1979, summarized ethical principles and guidelines for research involving human subjects. Three core principles were identified:
(i). Respect for persons: protecting the autonomy of all people and treating them with courtesy and respect and allowing for informed consent. Researchers must be truthful and conduct no deception;
(ii). Beneficence: the philosophy of "Do no harm" while maximizing benefits for the research project and minimizing risks to the research subjects; and.
(iii). Justice: ensuring reasonable, non-exploitative, and well-considered procedures are administered fairly — the fair distribution of costs and benefits to potential research participants — and equally.
These principles remain the basis for the United States Department of Health and Human Services (HHS) human subject protection regulation. Their close alignment with the principles advanced by Beauchamp and Childress for application in health care generally is obvious and completely in accord with the results of Kowalski, et al. [34].
Before passage of the Kefauver-Harris amendment in 1962, FDA approval did not require proof of the efficacy of new drug products. The impetus for this amendment was the devastation caused by thalidomide, a sedative used to treat morning sickness in pregnant women that was causing birth defects in other countries.
Federal action to prevent this from happening in the United States came via amendments to the Federal Food, Drug and Cosmetic Act. Commonly called the Kefauver-Harris Amendments, they were sponsored in Congress by Sen. Estes Kefauver (D-Tenn.) and Rep. Oren Harris (D-Ark.). Once signed into law by President Kennedy on Oct. 10, 1962, drug manufacturers were required to prove that a medication was not only safe, but effective.
We acknowledge that various differences exist between physical illnesses and mental illnesses when it comes to applications of the medical model. For instance, whereas the etiology and pathophysiology of physical conditions such as coronary artery disease, pneumonia, cystic fibrosis, etc. are known, researchers are still uncovering the neurochemistry, neurophysiology, and neuropathology of mental illnesses such as schizophrenia, bipolar disorder, and major depression. Such differences are important to the extent that they play a role in the DPR.
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Kowalski, C.J., Redman, R.W. & Mrdjenovich, A.J. The Doctor-Patient Relationship, Partnership Theory, and the Patient as Partner: Finding a Balance Between Domination and Partnership. Health Care Anal (2024). https://doi.org/10.1007/s10728-023-00473-9
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DOI: https://doi.org/10.1007/s10728-023-00473-9