Dr Jo Brown, Reader in Medical Education, Academic Director of the Student Experience, Head of Clinical Communication, National Teaching Fellow, St George's, University of London.
Dr Lorraine M Noble, Senior Lecturer in Clinical Communication, UCL Medical School, UCL, London, UK.
Dr Alexia Papageorgiou, Associate Professor in Clinical Communication, St George's, University of London medical programme, delivered in Cyprus by the University of Nicosia Medical School.
Dr Jane Kidd, Undergraduate Quality Manager, Education Training and Research, University Hospitals Coventry and Warwickshire NHS Trust; External tutor, Institute of Medical and Biomedical Education, St George's University of London.
History of the Doctor-Patient Relationship
Barts and the London School of Medicine and Dentistry, Queen Mary, University of London, London, UK
At the very heart of communication in healthcare lies the expectation of the doctor-patient relationship. The doctor is a healer, witness to suffering, interpreter of symptoms, educator, advocate, and a provider of treatment, comfort and access to services. Whilst the Hippocratic Oath of ancient times embodies the virtues and values within the relationship, the 'medical ideal' is varyingly shaped by the social, scientific, technological and political contexts of the day (Sigerist 1933).
From a trade to a profession
Historically medicine was more like a trade, and doctors were little more than superior servants of the rich who could afford their services. The latter shopped around and decided what they wanted, whilst the doctor complied with issuing treatments (Porter 1997). This was akin to a consumerist model for those who could afford it, whilst the doctor's success depended on the ability to attract patrons. Without standards of practice, quality control or accountability, the patient was vulnerable to quackery.
The birth of the profession in the UK came about through restricted practice with a set of standards established by the Royal Colleges in the 16th century (Warren 2000). Surgeons separated from barber-surgeons and became university educated when the London College of Surgeons was founded in 1745 (Science Museum 2014). These developments recognised academic rigour of physicians and surgeons, in contrast to a trade guild, but there was no 'social contract' with patients, and in fact doctors were more likely to flee epidemics during the 17th century than see any social obligation to stay and treat patients (Wynia 2008).
The modern use of the term 'professionalism' as a basis for the doctor's role towards individuals and society was first mooted in England by Dr Thomas Percival in 1803, but not until 1847 in the USA was it enshrined as a social contract demanding altruism, civic-mindedness, devotion to scientific ideals and a promise of competence and quality assurance through self-regulation (Wynia 2008). Interestingly it was accompanied by expectations that patients should communicate their problem, but not 'weary' the physician with 'tedious detail', and would obey the prescriptions of the physician (Baker et al. 1999).
The paradigm of illness underlying the practice of medicine has been dominated since the 17th century by the dualism of mind and body, attributed to the French philosopher René Descartes. Originally his ideas were motivated by religious intentions, in which he argued for the soul's immortality and maintained that the mind or soul can exist without the body (Skirry 2006). However, Cartesian Mind-Body dualism came to influence the systems-based approach to medicine and underpin the prevailing discourse within the doctor-patient relationship.
Rise of the scientific paradigm and dominance of the biomedical model
The scientific approach to medicine during the 19th century had a major impact on the role of the doctor. Medical care was revolutionised by the discoveries of the circulation of the heart and vascular system, the germ theory of disease and cell theory with its application to the effects of disease on tissues and organs (Hahn & Kleinman 1983). Doctors' status rose with their scientific knowledge, specialist equipment and professional code. Classifications based on the signs and symptoms of disease became the primary focus. The body was increasingly seen as a machine, and the disease, not the patient's experience of illness, became the object of study and treatment. The relationship was that of an expert doctor, with loss of humility and increased hubris (Wynia 2008), and the patient as a passive recipient of care.
The patient's account of his or her illness was subject to the same systematic approach and became known as 'the medical history'. Its importance in the diagnostic process was recognised by the Canadian physician William Osler, who revolutionised training by insisting that students learned from seeing and talking to patients on the wards. His admonition 'listen to your patient, he is telling you the diagnosis' highlighted the central role of the patient's narrative (Osler 1914). 'Taking a medical history' became part of clinical reasoning in establishing the causation of disease.
Biomedicine was the predominant model, based essentially on the belief that abnormalities in the body result in symptoms, and that health is the absence of disease (Hahn & Kleinman 1983). By embracing reductionism, the importance of the psychosocial aspect of illness and the patient's perspective went unrecognised and unacknowledged. As the patient's views were unimportant in this biomedical model, informed consent was also a nonexistent phenomenon.
From the late 19th century, psychoanalysis and talking therapies emerged to study the mind and explain conversion of psychological traumas to physical symptoms and expressions of unhappiness (European Graduate School n.d.). Whilst therapeutic alliance in the doctor-patient relationship was crucial to the healing process, the power resided with the doctor.
Healthcare as a right
In the UK in 1945, the creation of a National Health Service (NHS) by Aneurin Bevan brought about healthcare free at the point of need. The benign paternalism of the welfare state provided for the population 'from the cradle to the grave' (Beveridge 1942). This was a hugely significant historical moment, enshrining health as a right, and consultation rates increased enormously (Rivett 1998). Doctors now treated people from all socio-economic groups who were grateful, powerless and uncritical. The formers' success was dependent on approval from hospital superiors and not patients. The medical profession was reluctantly drawn into practising within an NHS, initially fearing control by the state, but they still had enormous freedom with state-sanctioned power and deferential patients.
Challenges to the biomedical model and rise of the biopsychosocial model
In the mid-20th century, sociology and psychology, new fields of discourse, joined the debate about the doctor-patient relationship. The American sociologist Talcott Parsons in 1951 referred to the 'sick role', in which patients were regarded as passive victims but were expected to want to get better by following the advice of the expert doctor (Parsons 1951). The patient was absolved of responsibility for their illness and allowed to abstain from their usual roles in society until they were better.
Recognising different contexts, the physicians Thomas Szasz and Marc Hollender described three basic models of doctor-patient relationship: activity-passivity, whereby the physician does something to an inert or unresponsive patient; guidance-cooperation, in which the physician tells the patient what to do and the patient complies; and mutual participation, whereby the physician helps the patient to help him- or herself and the patient participates as a partner (Szasz & Hollender 1956). In all situations however, 'compliance', essentially meaning obeying doctors' orders, was expected (Stimson 1974). In the name of reducing anxiety, the truth was often withheld from patients, and doctors made decisions about treatment (Freidson 1960). This 'benign paternalism' was the cornerstone of the relationship. Indeed one might characterise it psychodynamically, or in transactional analysis terms, as a parent-child type of relationship (Berne 1961). It was criticised for maintaining doctors' power base at the expense of respecting patient autonomy, and Eliot Freidson called for patients, as consumers, to be actively involved to negotiate effectively for services (Freidson 1986). The nature of the doctor-patient relationship was now up for debate.
Whilst the sociologists were concerned with issues of power, others such as George Engel, Michael Balint and Carl Rogers viewed the relationship through the lens of 'dynamic psychology'. Engel advocated the need for a new medical model that linked science and humanism and used the term 'bio-psychosocial-cultural' (Engel 1977). This integrated information concerning what was the matter with the patient and what mattered to the patient. Rogers, a humanistic psychologist, maintained that for a person to "grow", he or she needed an environment that provided genuineness, acceptance and empathy. Anyone in a therapeutic relationship, such as a doctor or therapist, needed to demonstrate unconditional positive regard, openness, warmth and a willingness to listen and understand the person (Rogers 1961). The goal was to empower the person to fulfil his or her potential. Rogers' work was hugely important in the 1960s, defining a basis for the doctor-patient relationship, specifying both underlying attitudes and skilled behaviours.
At the same time, the Hungarian psychoanalysts Michael and Enid Balint, working in the UK, recognised the...