Glass, Richard M. MD
Editorials represent the opinions of the authors and The Journal and not those of the American Medical Association.
Medicine is, at its center, a moral enterprise grounded in a covenant of trust. [1].
The patient-physician relationship is under siege. I believe there are two sources that underlie the distress experienced by many patients and physicians in their interactions with each other. First, there is an intensification of the tension between the science and the art of medicine. Second, there are severe strains related to the rapid changes in the economics of medical practice.
Concern about tensions between the science and the art of medicine is hardly new. In the first paragraph of his landmark 1927 JAMA article, Francis Peabody noted that the most common criticism of young physicians of that era was that "they are too 'scientific' and do not know how to take care of patients." [2] A physician can hardly be "too scientific" in the sense of having an understanding of a disease and the knowledge necessary to diagnose and treat it successfully. What Dr Peabody meant almost 70 years ago, and what is even worse today, is a narrow focus on the biology of disease that ignores important psychosocial factors and inhibits forming the kind of personal relationship with the patient that enhances effective diagnosis and treatment. As expressed in a recent newspaper commentary: "The CT and MRI scans, the lasers and the laparoscopies, the chemo-cocktails and DNA codes-- all the advances that make modern medicine so effective (and expensive) have isolated physicians from the patient as a person. In the process, the ancient therapeutic art of listening is being ignored, much to the dismay of many physicians who recognize the limits of technology" (Trafford A. The empathy gap. The Washington Post, August 29, 1995;6).
But there is no need to turn back the scientific clock in order to have good patient-physician relationships. For example, patients will benefit from the new paradigm of evidence-based medicine [3] as long as their physicians recognize that the emphasis on critical evaluation of empirical evidence from clinical research, and the de-emphasis on intuition and unsystematic clinical experience, as grounds for clinical decision making must occur in the context of a compassionate and empathic relationship. Sensitivity to emotional needs and empathic listening are essential if the physician is to communicate effectively with patients and deliberate with them in making decisions--even if those decisions can be informed by critical appraisal of empirical evidence from a computerized literature search, and particularly if decisions have to be made in one of the many gray zones of clinical practice. [4].
The compassionate and effective application of the best medical science to a particular patient is the essence of the art of medicine. Evidence-based medicine, with its emphasis on ascertainment and critical assessment of clinical science, is certainly not the problem here, as its proponents have made explicitly clear. [3,5] Rather, the problem is uncritical reliance on technical knowledge or procedures for diagnosis and treatment. [6] Such a technological focus may offer a veneer of scientific objectivity, but it actually obscures the diagnostic value of a careful history and creates a barrier to the treatment value of a caring relationship. Physicians should use the best science has to offer for their patients, but never in a way that neglect important psychosocial issues or the uniqueness of each patient as a person.
We also need more scientific studies of the patient-physician relationship, particularly regarding the effects of various types of communications and physician behaviors on outcomes of care. [3] As is true for psychotherapy, [7] controlled empirical studies can advance the science of the art and still leave room for individual styles and creativity in responding to unique problems.
Recent changes in the organization and economics of medical practice constitute the other major source of stress in the patient-physician relationship. These changes have increased the tension between medicine as a business and medicine as a profession. [8] The language of business has become pervasive in medicine, [6] with patients becoming customers, clients, or consumers and physicians becoming just one type of provider. This fundamental change in attitudes presents a threat to medicine as a learned profession with a strong ethical tradition and also strains relationships with patients, who rightly expect something different from their doctors than from consumer goods salespersons. The morality of the marketplace has perverse effects on physicians and their patients. [9].
In the new era of cost controls and managed care, the incentive to do more that was present in fee-for-service practice has shifted dramatically to the incentive to do less. The "less" usually includes less time spent with each patient, a fundamental threat to establishing a good patient-physician relationship. Additional threats in capitated or managed care settings include loss of physician autonomy to make clinical decisions in the best interests of patients, loss of patient trust, loss of continuity of relationships, and adversarial and ethical problems with financial incentives to limit care. [10,11] It is possible for managed care to deliver high-quality, cost-effective care, but only if the "management structure guarantees that bottom-line fiscal considerations do not intrude unduly on the medical decisions that providers make on behalf of individual patients." [12] The current trends emphasizing competition on costs rather than quality, corporate profits, and obscene executive compensation don't look very promising in this regard.
In this issue of The Journal, Laine and Davidoff [13] describe another development that suggests a more optimistic assessment of the patient-physician relationship: patient-centered medicine. This more direct focus on the patient's view of what is best for him or her may not have reached every physician's office or hospital, but Laine and Davidoff make the case for the widespread effects of this professional evolution on patient care, medical law, medical education, and quality assessment. Patient centering and good patient-physician relationships should reinforce each other since knowledge of the patient's viewpoint requires active listening, observation, and empathy (accurate and insightful awareness of the experience of another person). The authors note that patient centering does not mean turning over control to patients. The patient is not always right--again, business language often doesn't fit the profession of medicine--and in those situations (requesting antibiotics for a viral infection, for example) the patient's position needs to be understood and responded to with education rather than capitulation.
The article on patient-centered medicine launches a new section in JAMA called The Patient-Physician Relationship. We have previously published articles on this topic as Original Contributions, Special Communications, or Commentaries, depending on their content, but we hope that the new section with this designation will give this issue new visibility and the importance it deserves. The JAMA editors and editorial board agreed that the section title should list the patient first and should use the term "physician" to symbolize the intent of this new section. We encourage you to submit manuscripts for consideration for publication in this section. Manuscripts reporting original research results on this topic are particularly welcome. All submissions will be subject to our usual rigorous process of editorial assessment and peer review, and the section will appear only when suitable articles have been accepted after undergoing that review process.
The patient-physician relationship is the center of medicine. As described in the patient-physician covenant, it should be "a moral enterprise grounded in a covenant of trust." [1] This trust is threatened by the lack of empathy and compassion that often accompany an uncritical reliance on technology and by pressing economic considerations. The integrity of the profession of medicine demands that physicians, individually and collectively, recognize the centrality of the patient-physician relationship and resist any compromises of the trust this relationship requires.
Richard M. Glass, MD
Reprint requests to 515 N State St, Chicago, IL 60610 (Dr Glass).
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8. Lundberg GD. The failure of organized health system reform--now what? caveat aeger--let the patient beware. JAMA. 1995;273:1539-1541. [Fulltext Link] [Medline Link] [Context Link]
9. Kassirer JP. Managed care and the morality of the marketplace. N Engl J Med. 1995;333:50-52. [Medline Link] [Context Link]
10. Emanuel EF, Dubler NN. Preserving the physician-patient relationship in the era of managed care. JAMA. 1995;273:323-329. [Fulltext Link] [Medline Link] [Context Link]
11. Council on Ethical and Judicial Affairs, American Medical Association. Ethical issues in managed care. JAMA. 1995;273:330-335. [Fulltext Link] [Context Link]
12. Clancy CM, Brody H. Managed care: Jekyll or Hyde? JAMA. 1995;273:338-339. [Medline Link] [Context Link]
13. Laine C, Davidoff F. Patient-centered medicine: a professional evolution. JAMA. 1996;275:152-156. [Fulltext Link] [Medline Link] [Context Link]
JOURNAL OF THE AMERICAN MEDICAL ASSOCIATION; Managed Care Programs; Patient-Centered Care; Physician-Patient Relations; Communication