The Doctor Patient Relationship Part I

Observations of a Physician

During the course of my medical career I’ve observed momentous changes in the way patients and physicians interact with each other. During my medical school days in the early 1970s I observed how patients would look up to their doctors with great respect as the trusted expert who knew best how to take care of them. Typically they would entrust all aspects of their medical care to the judgment of the physician. For their part, physicians would follow the routine S.O.A.P. Protocol: (1) Subjective – history taking, (2) Objective – physical examination and laboratory testing, (3) Assessment – diagnosis of illness, and (4) Plan: treatment plan. The patient’s simple contribution to this protocol would be to answer questions about his present, past, family and social history. The physician did the rest. And I noticed that patients did not seem to object to the protocol. They made their simple contribution to the process and willingly followed whatever doctor thought best.

As an intern in Internal Medicine in the middle 1970s, we would have sign out rounds to the night shift when we finished our daily duties in the late afternoon. As we signed out our patients from the intensive care unit, we’d describe their diagnoses and treatment plans in great detail and end briefly by designating for each patient a code status so that the night shift intern would know how aggressively to treat a patient if s(he) were called for a code. One might say, Mr. X is “full code” (do everything) or Mr. Y is “DNR” (do not resuscitate). And we made these designations without consulting the family. That was standard procedure in those years. By today’s standards, our sign out protocol of designating code status without consulting family members would be illegal, if not immoral, but the issue was not so clear in those days. After all, the Karen Quinlan case was being argued at this precise time. That historic decision of the NJ Supreme Court in 1976 forever changed the way interns sign out the code status of their patients.

From ancient times until the 1970s, physicians were guided by the principle of beneficence (looking out for the good of the patient as they understood it and acting unilaterally in decision making). Indeed, physicians practiced beneficence to the point of paternalism. Doctors focused on the patient’s illness, and since she had the expertise to know the best course of treatment for that illness, she thought it best for the patient to act upon that knowledge without worrying the patient.

In the 1970s the doctor patient dynamic began to change dramatically with a growing recognition of the importance of patient autonomy in decision making. Instead of being the passive recipient of the medical care administered by their physicians, patients became active participants in the doctor patient relationship. In their beneficence doctors may strongly recommend a specific treatment plan but the patient has the right to be informed of the therapeutic options and the right to make the final decision. Autonomy requires the informed consent of the patient, which includes full disclosure of information in a way he understands and to which he fully consents without any outside constraint.

Edmund Pellegrino postulates several reasons for the ascendancy of patient autonomy in the doctor patient relationship:  participatory democracy, increasing moral pluralism, weakening of religion as the ultimate source of morality, better public education, general mistrust of authority, reaction against expansion of medical technologies, and entry of professional philosophy in the study of medical ethics. Perhaps the last two reasons are of special importance. With advances in modern technologies (in-vitro fertilization, organ transplantation, genomics, etc.) came a broad range of ethical dilemmas that transformed what was previously called medical ethics into a wider field we now call bioethics. One might say that theologians and physicians in past days were the key players in medical ethics, whereas in our day of rapid technological innovation philosophers and scientists have greater influence in the broader discipline of bioethics. And liberty which is the core principle of the liberal philosophical tradition is precursor of the principle of autonomy.

The ascendancy of respect for patient autonomy is but one of the many factors which have impacted the doctor patient relationship over the past four decades, yet it’s a very important and healthy development. The principle of autonomy serves as a fundamental critique to the Medical Model which physicians are taught. A Patient is not an Illness. Physicians need to incorporate the whole person with her unique value structure into a process of shared decision making.

Part II posted in July will explore various models of the doctor patient relationship.