Doctor Patient Relationship, Part II: Theoretical Models and Clinical Reality
Theoretical Models
In 1972 Robert Veach postulated four models of the doctor-patient relationship: (1) Priestly, (2) Engineering, (3) Collegial and (4) Contractual. The Priestly Model dates back to the Hippocratic tradition: “I will use treatment to help the sick according to my ability and judgment, but I will never use it to injure or wrong them”. In other words, the physician makes all decisions regarding medical care of the patient based on his medical expertise and assessment of the patient’s best interests, without consulting the patient. The Hippocratic, priestly physician operates on the medical model, which treats patients as illnesses, not as persons. The priestly physician does not take into account a patient’s value system which includes a broad range of considerations beyond illness that might impact decision making. The paternalistic, Priestly Model of the doctor-patient relationship remained dominant from the time of Hippocrates (4th century B.C.) until the 1970s when Veach first wrote on the subject.
The Engineering Model switches the locus of decision making from physician to patient. The physician becomes a “hired gun” who relays the medical facts to the patient who then has full authority to select whichever treatment option he thinks is most consistent with his needs and desires, and then the physician implements the patient’s decision. In this model, the physician is like a plumber who, hired by a client, uses the skills of his trade to make repairs and flush out clogged pipes. He is a reservoir of scientific knowledge and dispenser of medical facts, presenting options to the patient without sharing his personal recommendations.
In the Priestly Model the patient relinquishes his moral authority and puts full decision-making responsibility in the hands of the physician; contrariwise, in the Engineering Model the physician abdicates his moral authority, reduces his role to that of a scientific expert who presents medical findings in a factual, value-free way and then places the full responsibility of decision-making in the hands of the patient.
Over the past 4 decades the once dominant Priestly Model with its centuries-old Hippocratic ethic has lost ground to the Engineering Model which better describes the dominant physician-patient dynamic in the modern medical marketplace. The movement from primary care to specialization in the medical profession, with emphasis shifting from conversation with patients to performance of procedures, is one manifestation of its emergent influence. Another is the growing perception that medical care is a commodity to be bought and sold at a competitive price. Physicians are referred to as health care providers, not health care professionals; patients are consumers of a health product.
From the times of Hippocrates until the 1970s, physicians were guided by the principle of beneficence to the extreme of paternalism (looking out for the good of the patient as they understood it and acting unilaterally in decision making). Beginning in the 1970s the doctor-patient dynamic began to change dramatically with a growing recognition of the importance of patient autonomy in decision making. The newer models of the doctor-patient relationship reflect a trend toward more interaction and dialogue between patient and physician in a collaborative process to discern the health care decision that is not only “medically indicated” but also most aligned with patient values.
A strong advocate of patient autonomy and critic of the Hippocratic tradition, Robert Veach in 1972 was the first to postulate a collaborative model of the physician patient relationship. In the Contractual Model of collaboration, physician and patient forge a mutually agreeable contract, more like biblical covenant than legal construct. There is true sharing of decision making in such a way that both physician and patient can be confident of retaining their moral integrity. The basic principles of autonomy, fidelity, voracity, avoiding killing and justice are essential to their contractual relationship. Physician and patient, through open discussion and exchange of views, establish a mutually agreeable value framework for medical decision making. In this way the physician is able to make the myriad decisions regarding medical care on a daily basis without consulting the patient on every detail.
Twenty years after Veach, Ezekiel Emanuel and Linda Emanuel proposed 4 Models of the physician-patient relationship. The first two are very similar to Veach’s: Paternal Model (like Priestly) and Informative Model (like Engineering). However, their two collaborative models (Interpretative and Deliberative) spell out the role of the physician in greater detail than Veach.
In the Interpretative Model, the physician acts like a counselor whose role is to elucidate and interpret the patient’s values, and then to assist him in determining the medical interventions which would best realize the specified values. It presumes that people are often unclear about their values and that discussion with another would help them apply their value system to clinical situations. The counselor physician acts as a facilitator in the process and does not introduce his value structure into the discussion. He helps the patient reconstruct his goals and aspirations, his character and life commitments. Once the physician understands the patient’s value system, he determines which tests and treatments would best realize these values. This final step resembles Veach’s Contractual Model since it’s not necessary that patients be involved in every detail of decision-making once the patient’s value structure is established. Yet in both models, the patient is the center of decision-making and has full moral authority.
In the Deliberative Model, the physician takes a much more active role in the collaborative dynamic. He presumes that the patient’s values are open to development and revision through moral discussion. He articulates and persuades the patient of the most admirable values. Like a teacher he explains what course of action in his judgment is not only “medically indicated” (Informative Model) but also most noble. Thus, the physician presents his medical and moral judgment up front in the discussion and uses his skills of persuasion based on clinical experience and firm opinion, yet ultimately he leaves the final decision to the patient.
It seems to me that none of the models apply in all clinical circumstances. In an emergency, clearly the Priestly/Paternalistic Model would apply since there is no time for discussion about values and preferences. It may also apply in some agrarian, third world cultures where the patient traditionally places all decisions in the hands of the physician and defers to his family all discussion with the physician. But in our modern pluralistic society, it would be foolish to presume physician and patient would espouse similar values and views of what constitutes a benefit, thus this paternalistic model would rarely apply now. The Engineering/Informative Model would be operative when medical facts are all that’s needed, e.g. when a specialist is consulted for a second opinion to confirm a diagnosis. But it erodes the virtue of caring so integral to the medical profession by reducing the role of a physician to a medical technician, disengaged from any meaningful relationship with his patient. It seems to me that both physician and society bear responsibility for the rising influence of this model. Doctors may be reluctant to make firm recommendations for fear of litigation if their opinion leads to a bad patient outcome. And in a consumer society, medical goods are like other commodities that can be bought and sold at the marketplace. Doctors need to be more courageous and society needs to regain its moral bearings.
Under most day to day circumstances, I would advocate discussion and collaboration between physician and patient. And like the Emanuels, I prefer the deliberative model, which requires alignment of medical decisions with the patient’s value system and, at the same time, engages the physician more directly and integrally in the process of working out the best decision. It encourages the physician to state frankly and directly his specific treatment recommendation and to explain how the decision is consistent with the patient’s most noble values. It seems to me this depth of deliberation is rarely possible in one visit, but rather requires a history of ongoing relationship. A primary care physician who sees a patient over a long period of time is in a perfect position to use the deliberative dynamic without much difficulty. And in the context of intensive care, an intensivist who sees patient and family at least daily can use the deliberative dynamic more easily than with a specialist who sees the patient only once or twice.
Clinical Reality
Theoretical models are helpful for discussion but do they apply in real life clinical medicine? In a provocative article entitled “No more models: just ask the patient”, Clark et al argue that the common theoretical models of “preferred” decision making relationships do not correspond well with clinical experience. The theoretical models of doctor patient relationship treat the patient alone outside of his or her family and social context. Yet typically the patient does not want to make decisions alone. Most patients prefer family or friends to be involved and they want advice from a spouse, son or daughter before they make a final decision. And at times they delegate decisions to someone they think has better judgment or a better grasp of the facts. As long as the physician patient model is that of an individual autonomous patient and a single physician in a decision making context, the preferences of such patients would be ignored. In short, there appears to be considerable variety in patients’ preferences for decision models, so the search for a single best model is based on a misguided assumption that one protocol fits all.
Physicians will be guided in the right direction, and will actively take into account the differences between individual patients, if they begin the process by asking the patient a few simple questions: (1) how do you want communication and decision-making to be handled?, (2) who do you want to be present for support and advice when the physician discusses treatment options with you?, (3) how much information about the case do you want the doctor to tell you?, and (4) in which of the many clinical decisions do you want to participate? The answer to these questions would set parameters for the collaborative process of decision making within the family and social context of the patient’s life. Given the variety of patient desires concerning communication, it seems unreasonable to believe that any one model of decision-making will fit all patients.
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i Veach R. “Models for ethical medicine in a revolutionary age“. Hastings Center Report: 1972 (June): 2(3)
ii Emanuel EJ and Emanuel L “Four Models of the Physician-Patient Relationship”. Journal of the American Medical Association 1992: 267 (16); 2221
iii Clarke G, Hall RT and Rosencrance G. “Physician-Patient Relations: No More Models”. The American Journal of Bioethics 2004: 4(2), 16- 19.