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Patient-doctor relationship models

15 January 2023

In colloquial conversations, there are disputes about whether an efficient doctor or a kind and sympathetic one is better. Even at first glance, however, it is clear that there is something wrong with this kind of dispute. After all, when we go to the doctor, we are not only interested in getting effective advice, or only in seeing a doctor in a pleasant atmosphere. We will remember the advice of a doctor who is efficient but does not show good manners with regret rather than as an event that went well. We will also derive little benefit from seeing a doctor who is friendly, polite and perhaps understanding, but who is unable to diagnose correctly the problem we have come to see him or to plan an effective treatment. We expect a visit to the doctor to be the right answer to the problem we are presenting. And this problem is often not reduced to a disorder or illness, but covers many aspects of a person's life. Hence, it is important that we know how to shape a correct doctor-patient relationship so that the visit fulfils its purpose.

When discussing the doctor-patient relationship, researchers often use the concept of a model of the doctor-patient relationship. The word model here means a schematic description of a situation that rarely or never occurs in reality in exactly this form, but contains the key elements of this situation. By comparing reality with the model, we can assess how the visit went and which legitimate expectations were fulfilled and which were not. Naturally, the doctor is not expected to follow the model perfectly. The model is an approximation that allows us to orient ourselves to reality. The preferred model, on the other hand, represents the ideal to which one should aspire in practice. By comparing different models, one can choose the one that most closely matches expectations in specific circumstances.

In order to better understand the value of using models of the patient-doctor relationship, it is also important to note that this relationship involves many often divergent values and expectations, as well as specific experiences that are different for the doctor and different for the patient. This different perspective and experience of the doctor and the patient is most often captured by the distinction between sickness and illness. The patient's perspective is characterised by the experience of illness, i.e. Sickness. More often than not, it is a surprising phenomenon because it interferes with the patient's plans. Nobody or almost nobody plans to be ill. Illness is therefore generally an obstacle to the realisation of plans. It is also an event that is generally unique and specific to a particular person, because it affects the biography, values, plans and aspirations of that person and not of others. The patient usually looks at his illness from the point of view of his life experiences. He or she generally tries to explain his or her illness by past events or other life circumstances. Different patients also evaluate illness differently. For some, being ill is just a hindrance, while for others it can represent a questioning of what is most important to them.

The patient's problem is usually viewed differently by the doctor, for whom the disease is usually a recurring phenomenon that he understands from the point of view of medical knowledge and professional experience. The doctor, therefore, understands the disease less as an element of his biography and more as part of a causal chain that must be explained and appropriate measures found to break or reverse it. The patient's illness is also an everyday phenomenon in the doctor's life, and treatment is a repetitive activity that does not question his priorities. These differences in the perspectives of the patient and the doctor mean that an appropriate model of the relationship between them must, on the one hand, take into account the discrepancies and, on the other, open up the possibility of agreeing on common priorities in the process of diagnosis and treatment.

There are many approaches to the doctor-patient relationship to be found in the bioethics literature. Here, it is worth distinguishing three of them: paternalistic, engineering and partnership. Discussing them allows us to see how different and differently relating to our expectations the doctor-patient relationship can be. It also allows us to notice aspects of this relationship that usually escape our attention and may be underestimated. Models of the doctor-patient relationship will be discussed in the order in which they appeared in the history of medicine. This does not imply that the models of the past are not implemented today or that the model preferred today was not implemented in the past.

The oldest is paternalistic model. It is dominated by the doctor who, with his knowledge and experience, is able to correctly identify the patient's problem and then design an appropriate therapy. This model is characterised by the fact that it assumes a priori that the doctor in each case is able to determine for himself or herself what a particular patient's problem is in particular and how it should be remedied. This means that the doctor is seen here as an expert not only on health and illness, but also on priorities and values. This model reflects the traditional view of the doctor's role. It derives from the origins of Western medicine and can be found, for example, in the so-called Hippocratic Oath. The author of this document undertakes to prescribe remedies according to his or her best knowledge and discernment. The patient's opinion is not sought in this matter because, one would think, the doctor knows better what is in the best interests of his patient.

This model seems appropriate in a society where there are no fundamental divergences on issues of values or worldviews. The ancient Greek doctor mainly cared for patients who belonged to the same social stratum as he did, had the same religious beliefs and outlook on life priorities. His work therefore did not require the setting of fundamental priorities in the diagnostic and therapeutic process and could be reduced to identifying problems and prescribing remedies that fell within the boundaries set by the values and views shared by the doctor and the patient.

Today, this model must give rise to difficulties. More and more often and to an increasing extent we differ in our views, and these differences are particularly evident in the area of medicine and the doctor-patient relationship. Because we have different views, it is increasingly difficult for doctors to predict what the views of a particular patient are and what constitutes a problem for that patient and the scale of that problem. The paternalistic model of the doctor-patient relationship is therefore inappropriate in the vast majority of contemporary patient-doctor relationships. This model may be helpful in homogeneous and traditionalist societies, but not in today's dynamic and diverse democratic societies. In such societies, it is downright harmful because it encourages ignoring the patient's expectations and opinions and pressurising the patient with the authority of medicine behind it.

The opposite of the paternalistic model is the engineering model. According to this approach, the doctor is only an expert on health and illness and is not interested in the patient's values, preferences and views. His or her task is to obtain clear information as to what the patient's expectations are and then to present the most optimal way to meet these expectations. According to this model, it is the patient who decides the priorities and goals of the relationship with the doctor, and the doctor provides only technical expertise and implements appropriate actions. The engineering model is neutral when it comes to issues of values, priorities and worldviews. It encourages the doctor to be treated as an expert at getting things done according to order, removing the burden of encroaching on values.

The engineering model of the doctor-patient relationship diverges from colloquial notions of what medical care is about. The doctor-patient relationship is an ethical relationship because it involves key moral values. Removing values from the doctor's view of his or her relationship with the patient must result in his or her indifference to, for example, the patient's concerns or his or her human need to enter into meaningful relationships. Thus, in a patient-physician relationship shaped according to the engineering model, the patient's expectations of his or her values will not be met, so that he or she will not receive care that is responsive to his or her needs. Moreover, the engineering model also encourages an abstraction from the values the doctor believes in. Consequently, in such a relationship, the doctor may be forced to take actions that ignore or conflict with his or her values and beliefs.

An alternative to the paternalistic and engineering model is the partnership model. This model is based on the fundamental ethical assumption of moral equality of the parties to the doctor-patient relationship and, at the same time, respect for differences. It is assumed here that the doctor and the patient may differ significantly in their values and priorities in life. On the one hand, this situation requires the values, priorities and expectations of the parties to the relationship to be presented in order to determine what the patient's problem is. On the other hand, it allows for the joint development of appropriate ways to remedy the problem. In this model, the values and views of the doctor and the patient set the boundaries of what each party's reasonable expectations will be.

The doctor's determination of what the patient's values and views are allows the doctor to go beyond a purely biomedical view and assess what the patient's problem is from the latter's perspective. In this way, the patient and doctor can jointly determine what will be acceptable solutions to the problem so understood. For example, a skin lesion in a visible area will be more of a problem for a person in a job where appearance is an important factor for professional success than for someone whose job does not involve such demands. A problem caused by the same biological phenomenon will be defined differently for each of the two people and will have a different significance for each of them. Similarly, their expectations of the proposed treatment intervention may be different. A scar from the removal of a skin lesion may be a major problem for the former and of marginal importance for the latter.

Incorporating the values of the doctor and the patient into the partnership model also makes it possible to establish an authentic relationship between them. Such a relationship is neither reduced to the domination of the doctor, who "knows better what is best for the patient", nor to the indifference of the doctor to the patient's difficult life situation. In a partnership relationship, the doctor and the patient are equal co-workers who seek to understand each other and fulfil expectations in line with the beliefs and values of both parties. The ethical centre of the partnership relationship is joint decision-making by patients and doctors.

A relationship shaped according to the partnership model requires both the doctor and the patient to be mutually respectful, tolerant and open, and to avoid judging the other party or criticising his or her views. The doctor-patient partnership also requires empathy based on the ability to imagine the patient's situation, as well as an effective communication with the patient. Empathy and communication skills enable the doctor to understand the patient's values, needs and expectations, which increases the likelihood of accurately diagnosing the patient's problem and offering treatment in line with them. Patients, in turn, who are met with an empathetic attitude from a doctor who communicates efficiently with them, will be ready to give it trustand are thus more likely to follow recommendations that are aligned with their values, views and expectations.

Prof. Dr. Paweł Łuków(Polish philosopher and ethicist, professor of humanities, university teacher)