- ■ Trust, knowledge, regard, and loyalty are the 4 pillars of The Doctor-patient Relationship, significantly influencing patient health outcomes.
- ■ Factors impacting this relationship can stem from the patient, the healthcare provider, the health system, or mismatches between patient and provider.
- ■ Solutions to strengthen the doctor-patient relationship are fundamentally linked to these four core elements.
Have you ever paused to consider the profound impact of the doctor-patient relationship? Reflected on how to nurture and fortify this bond, or what happens when it weakens or breaks down? Contemplated the repercussions of a strained or even adversarial dynamic between doctor and patient? If these questions resonate with you, the following case studies and discussion will offer valuable insights.
CASE VIGNETTE 1
Meet Mr. A, a 43-year-old man with a two-decade history of intravenous drug use, further complicated by hepatitis C and recurring abscesses. He was admitted to the hospital to address acute bacterial endocarditis. The inpatient medical team sought expertise from the addiction consultation/substance use team. Following their evaluation, Mr. A was enrolled in an outpatient methadone clinic. Remarkably, Mr. A shared that this consultation marked the first time he had ever had a truly “meaningful” conversation about addiction treatment.
CASE VIGNETTE 2
Introduce Ms. B, a 75-year-old woman managing both an alcohol use disorder and gastroesophageal reflux disease. She arrived at the oncology clinic following an unexpected diagnosis of gastric carcinoma. During her appointment, the oncologist meticulously explained the critical importance of assessing the tumor’s depth of invasion into her stomach wall – essential for staging the cancer and determining the most effective treatment path. He clarified that if the tumor remained confined to the stomach’s surface layer, it could potentially be removed endoscopically. However, if it penetrated deeper, Ms. B would likely require radiation, chemotherapy, or surgery. The oncologist promptly arranged a consultation with a surgeon. The surgeon informed Ms. B that the cancer was almost certainly invasive and that he intended to remove a significant portion of her stomach. He described the surgery as highly serious, yet necessary, due to the high likelihood of her cancer being fatal if untreated. As the surgeon turned to document his notes in the electronic medical record, Ms. B began to weep and shake her head in distress.
THE PROFOUND IMPORTANCE OF THE DOCTOR-PATIENT RELATIONSHIP
The doctor-patient relationship is inherently built upon vulnerability and trust. It stands as a profoundly human experience, often deeply moving and meaningful. However, the reality of this relationship, and the healthcare interactions it shapes, is not always ideal.
The doctor-patient relationship is formally defined as “a consensual relationship in which the patient knowingly seeks the physician’s assistance and in which the physician knowingly accepts the person as a patient.”1(p6) Fundamentally, this relationship is fiduciary, meaning the physician, by entering into it, commits to uphold patient autonomy, maintain strict confidentiality, clearly explain treatment options, secure informed consent, deliver the highest standard of care, and not abandon the patient without allowing sufficient time to find alternative medical care. Yet, this contractual definition barely scratches the surface of the doctor-patient relationship’s immense and profound nature. Patients often share their deepest secrets, anxieties, and fears with their doctors – revelations they may not have even shared with their closest friends or family. This deep trust in a physician is pivotal in helping individuals maintain or regain their health and overall well-being.
This unique relationship is composed of four essential elements: mutual knowledge, trust, loyalty, and regard.2 Knowledge refers to the doctor’s understanding of the patient as an individual, and conversely, the patient’s understanding of their doctor. Trust embodies the patient’s confidence in the doctor’s competence and caring nature, as well as the doctor’s trust in the patient, their beliefs, and the symptoms they report. Loyalty is reflected in the patient’s willingness to forgive the doctor for minor inconveniences or mistakes, and the doctor’s unwavering commitment not to abandon their patient. Regard signifies the patient’s feeling that their doctor genuinely likes them as a person and is truly “on their side,” advocating for their best interests. These four elements are the bedrock upon which a strong doctor-patient relationship is built.
Alt text: Empathetic doctor reviewing test results with a concerned patient, demonstrating trust and open communication in a healthcare setting.
STRUCTURAL MODELS OF THE DOCTOR-PATIENT RELATIONSHIP
In their groundbreaking 1956 article, Szasz and Hollender3 proposed three fundamental models that define the doctor-patient relationship:
Active-Passive Model
The active-passive model represents the oldest of these frameworks. It is characterized by the physician acting on the patient, often treating the patient as a passive recipient of care, akin to an inanimate object. This model can be appropriate in critical, emergency situations where the patient is unconscious or when any delay in treatment could lead to irreversible harm. In such urgent scenarios, informed consent and extensive discussions are necessarily bypassed.
Guidance-Cooperation Model
The guidance-cooperation model positions the doctor in a role of authority, leveraging their specialized medical knowledge that the patient typically lacks. In this model, the doctor is expected to determine the patient’s best course of action and provide clear recommendations. The patient, in turn, is expected to follow these recommendations diligently.
Mutual Participation Model
The mutual participation model emphasizes an equal partnership between the doctor and the patient. The patient is recognized as an expert in their own life experiences, values, and goals, making their active involvement crucial in shaping their treatment plan. The physician’s role shifts to eliciting the patient’s personal goals and collaboratively working towards achieving them. This model necessitates that both parties possess comparable power, are mutually reliant on each other, and engage in interactions that are equally rewarding and satisfying for both.
While each of these models may be suitable in specific contexts, the mutual participation model has gained increasing support over recent decades, particularly when medically feasible.4 This shift reflects a growing recognition of patient autonomy and the importance of shared decision-making in healthcare.
Alt text: Doctor and patient actively collaborating on a treatment plan, highlighting shared decision-making and patient involvement in healthcare.
THE IMPACT OF THE DOCTOR-PATIENT RELATIONSHIP ON HEALTH OUTCOMES
Gordon and Beresin5 convincingly argue that negative health outcomes – whether measured objectively or through standardized subjective metrics post-encounter – often stem from a compromised doctor-patient relationship. This breakdown can occur when patients feel unheard, disrespected, or excluded from a genuine partnership with their physicians.6 Health outcomes are diverse and multifaceted, but can be broadly categorized into three main domains: physiologic/objective measures, behavioral measures, and subjective measures. Table 1 provides examples of outcome measures within each of these categories.
Table 1. Health Outcome Variables Related to the Doctor-Patient Relationship
| Outcome Category | Outcome Variable |
|---|---|
| Objective | Blood pressure |
| Frequency of visits | |
| Knowledge/recall | |
| Serum glucose level | |
| Serum triglyceride level | |
| Survival | |
| Behavioral | Adherence to treatment |
| Coping | |
| Emotional status | |
| Functional status | |
| Recovery | |
| Subjective | Global health status |
| Knowledge | |
| Pain | |
| Satisfaction | |
| Understanding |
Stewart et al.7 established a significant positive correlation between a physician’s in-depth understanding of a patient’s ailments and emotional state and the successful resolution of those physical ailments. In this context, the outcome measure is the alleviation of symptoms, signifying patient recovery.
In a subsequent meta-analysis examining the impact of doctor-patient communication on health outcomes, Stewart8 further highlighted that the quality of communication during history-taking and treatment management profoundly affects outcomes. These include frequency of visits, emotional well-being, and symptom resolution. Crucially, this effective communication extends beyond simply creating a treatment “plan.” The manner in which a physician communicates with a patient, even during the initial information-gathering stage, significantly influences whether, and how often, a patient will seek care from that physician again.
Moreover, high-quality doctor-patient communication involves the physician’s willingness to actively include the patient in the decision-making process, provide them with relevant information and educational resources, and inquire about the patient’s personal explanatory model of illness – their individual perception of their disease shaped by their customs and beliefs.9,10 This patient-centered approach fosters trust and improves adherence to treatment plans.
PATIENT SATISFACTION AND ITS LINK TO THE DOCTOR-PATIENT RELATIONSHIP
Patient satisfaction is defined as “the degree to which the individual regards the health care service or product or the manner in which it is delivered by the provider as useful, effective, or beneficial.”11 Each of the four core elements of the doctor-patient relationship – trust, knowledge, regard, and loyalty – plays a critical role in shaping patient satisfaction levels.
Trust. Bennett et al.12 discovered that among patients with systemic lupus erythematosus, those who expressed trust in and liking for their physicians reported significantly higher levels of satisfaction. Another study13 corroborated this, finding that patients’ perceptions of their physician’s trustworthiness were primary drivers of their overall satisfaction with care.
Knowledge. Patient satisfaction demonstrably increases when doctors actively identify and address patient concerns and expectations. Similarly, allowing patients ample opportunity to share information about their health experiences also boosts satisfaction levels.14,15 This emphasizes the importance of active listening and patient input.
Regard. Patient satisfaction is strongly linked to patients’ ratings of their physician’s friendliness, warmth, emotional support, and overall caring demeanor.16–18 Patients value feeling respected and cared for as individuals.
Loyalty. Patients report higher satisfaction when doctors offer consistent and ongoing support. Continuity of care is a significant factor in enhancing patient satisfaction.13,14 Building long-term relationships contributes to a sense of security and trust.
Alt text: Smiling and satisfied patient exiting a doctor’s office, symbolizing positive patient experience and satisfaction with healthcare.
FACTORS THAT CAN IMPEDE THE DOCTOR-PATIENT RELATIONSHIP
While the desirable attributes and benefits of a strong doctor-patient relationship are well-documented, fewer studies have focused on providing practical solutions for when this relationship is strained or impaired. To address this gap, we propose four categories of factors that can negatively impact the doctor-patient relationship: patient factors, provider factors, patient-provider mismatch factors, and systemic factors.
Tables 2–5 offer a comprehensive overview of the major factors within each category. For each factor, they identify the elements of the doctor-patient relationship that are most affected and suggest potential solutions to mitigate negative impacts. It is important to acknowledge that these tables are not exhaustive and represent a starting point for understanding the complexities of the doctor-patient relationship.
Table 2. Patient Factors That Affect the Doctor-Patient Relationship and Suggested Solutions for an Impaired Relationship
| Patient Factors | Strains on Relationship | Solutions
