The patient-physician relationship: is three a crowd?

OPEN AND FRANK COMMUNICATION BETWEEN DOCTORS AND THEIR patients has always been the cornerstone of effective health care delivery. Patients willingly relinquish detailed information about their physical conditions plus personal and family histories to which few people, if any, are ever privy. Physicians are entrusted to use this private knowledge, not for personal gain, but to provide curative and palliative therapies that will unconditionally improve the patient’s well-being. These straightforward aims are threatened by the practical difficulties that arise when the competing objectives of other parties (nonphysician and nonpatient) enter the situation. As described by Joel Schofer and Martin Furmanski, societal exigencies can impinge on the relative sanctity of the patient-physician relationship, as during wartimes when government directives have contravened the privacy of the patient-physician relationship. Fortunately, such situations rarely occur. A more urgent factor changing the nature of the patient-physician relationship is the increasing prominence of cost containment in medical practice and the resulting pressure on physicians to see more patients in the same amount of time. As in any other human relationship, trust between the physician and patient requires time to become established. The patient may be initially skeptical of the physician’s abilities or intentions and withhold information necessary for a medical diagnosis. The physician may require time to attune to the behavior and speech nuances of a particular patient and appreciate the complete story. How long does it take for effective communication to happen? As Dan Reirden recounts in this issue, years can go by, and the physician may still not be completely aware of the circumstances surrounding a patient’s illness. In this age of 15-minute office visits, one can only wonder how much information that could have been useful in treating a patient’s condition is left unsaid. Other factors modify the way patients and physicians interact with one another. The growing number of non–Englishspeaking patients has necessitated introducing multilingual intermediaries between the physician and patient. As Lorna Breen discusses in this issue, information can be readily lost or distorted as the message is translated from one language to another. The articles in this and future issues of MSJAMA touch on only a few of the challenges faced by physicians in providing personalized and competent health care. As the new academic year begins, medical students would be well advised to keep abreast of the medical implications of changes in the patient population and, perhaps most importantly, the growing dominance of financial incentives in shaping the manner in which physicians interact with their patients.