The Doctor-Patient Relationship

Impacting the Success of Treatment

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The good physician treats the disease; the great physician treats the patient who has the disease ~ William Osler (Canadian Physician, 1849-1919)

Have  you ever wondered what patients want from an encounter with a doctor? In the thoughts of one physician (Delbanco,1992):

  • Patients want to be able to trust the competence and efficacy of their caregivers.
  • Patients want to be able to negotiate the health care system effectively and to be treated with dignity and respect.
  • Patients want to understand how their sickness or treatment will affect their lives, and they often fear that their doctors are not telling them everything they want to know.
  • Patients want to discuss the effect their illness will have on their family, friends, and finances.
  • Patients worry about the future.
  • Patients worry about and want to learn how to care for themselves away from the clinical setting.
  • Patients want physicians to focus on their pain, physical discomfort, and functional disabilities.

The Relationship

The relationship between patient and doctor has been analyzed since the early 1900's. Prior to when medicine was more science than art, physicians worked to refine their bedside manner, as cures were often impossible and treatment had limited effect.

In the middle of the century when science and technology emerged, interpersonal aspects of health care were overshadowed. There is now a renewed interest in medicine as a social process.

A doctor can do as much harm to a patient with the slip of a word as with the slip of a knife.

Instrumental and Expressive Components

The doctor-patient relationship crosses two dimensions:

  • instrumental
  • expressive

The "instrumental" component involves the competence of the doctor in performing the technical aspects of care such as:

The "expressive" component reflects the art of medicine, including the affective portion of the interaction such as warmth and empathy, and how the doctor approaches the patient.

Common Patient-Doctor Relationship Models

The Activity-Passivity Model - Not the Best Model for Chronic Arthritis

It is the opinion of some people that the differential in power between the patient and doctor is necessary to the steady course of medical care. The patient seeks information and technical assistance, and the doctor formulates decisions which the patient must accept. Though this seems appropriate in medical emergencies, this model, known as the activity-passivity model, has lost popularity in the treatment of chronic conditions, such as rheumatoid arthritis and lupus. In this model, the doctor actively treats the patient, but the patient is passive and has no control.

The Guidance-Cooperation Model - The Most Prevalent Model

The guidance-cooperation model is the most prevalent in current medical practice.

In this model, the doctor recommends a treatment and the patient cooperates. This coincides with the "doctor knows best" theory whereby the doctor is supportive and non-authoritarian, yet is responsible for choosing the appropriate treatment. The patient, having lesser power, is expected to follow the recommendations of the physician.

 The Mutual Participation Model - Shared Responsibility

In the third model, the mutual participation model, the doctor and patient share responsibility for making decisions and planning the course of treatment. The patient and doctor are respectful of each others expectations, point of view, and values.

Some have argued that this is the most appropriate model for chronic illnesses, such as rheumatoid arthritis and lupus, where patients are responsible for implementing their treatment and determining its efficacy. The changes in the course of chronic rheumatic conditions require a doctor and patient to have open communication.

What Is Truly the Optimal Model for Chronic Arthritis?

Some rheumatologists may feel that the optimal doctor-patient relationship model is somewhere between guidance-cooperation and mutual participation. In reality, the nature of the doctor-patent relationship likely changes over time. Early on, at the time of diagnosis, education and guidance is useful in learning to manage the disease. Once treatment plans are established, the patient moves towards the mutual-participation model as they monitor their symptoms, report difficulties, and work with the doctor to modify their treatment plan.

The Effectiveness of Treatment

The effectiveness of treatment is largely dependent on the patient carrying out the directions of the physician (i.e., compliance). Treatment options for arthritis may involve:

Non-adherence to the treatment plan presupposes a negative outcome, with the assumption that:

  • the treatment is appropriate and usually effective
  • there is an association between adherence and improved health
  • the patient is able to carry out the treatment plan

What Are the Effects of an Effective Patient-Doctor Relationship?

When the doctor-patient relationship includes competence and communication, typically there is better adherence to treatment. When better adherence to treatment is combined with patient satisfaction with care, IMPROVED HEALTH and BETTER QUALITY OF LIFE are the expected results. Bottom line: The success of treatment can be greatly impacted by the doctor-patient relationship.


Understanding Rheumatoid Arthritis by Stanton Newman, Ray Fitzpatrick, Tracey A. Revenson, Suzanne Skevington, and Gareth Williams. Published by Routledge. 1996.

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