The doctor-patient relationship is central to the practice of medicine and is essential for delivery of high quality health care in the diagnosis and treatment of disease.

The doctor-patient relationship is multilayered, dynamic, and bilateral. It has been 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. However, such a contractual definition fails to portray the immense and profound nature of the doctor-patient relationship. Patients sometimes reveal secrets, worries, and fears to physicians that they have not yet disclosed to friends or family members.

The relationship between the doctor and patient is a fiduciary relationship. This bond of trust between the doctor and the patient is essential to begin the process of healing. Doctors must adhere to the principles of medical ethics (autonomy, nonmaleficence, beneficence, and justice), rules (fidelity, confidentiality, privacy, and veracity), and virtues (compassion, kindness, respect, etc.) in their interactions with the patients, which have been laid down by various professional bodies and associations as professional codes of conduct and standards for doctors. The Hippocratic Oath, the oldest of these codes of ethics, still holds true today.

The doctor-patient relationship is in itself therapeutic; a successful consultation with a trusted doctor will have beneficial effects irrespective of any other therapy given. A patient hearing and empathy result in quality care that builds mutual faith, respect, and trust between doctor and patient. Therefore, it is important for physicians to recognize when the relationship is challenged or failing. If the relationship is challenged or failing, physicians should be able to recognize the causes for the disruption in the relationship and implement solutions to improve care. 

This unique relationship encompasses 4 key elements: mutual knowledge, trust, loyalty, and regard, which constitute the foundation of the doctor-patient relationship.

·  Knowledge refers to the doctor’s knowledge of the patient as well as the patient’s knowledge of the doctor.

·  Trust involves the patient’s faith in the doctor’s competence and caring, as well as the doctor’s trust in the patient and his or her beliefs and report of symptoms.

·  Loyalty refers to the patient’s willingness to forgive a doctor for any inconvenience or mistake and the doctor’s commitment not to abandon a patient.

·  Regard implies that the patients feel as though the doctor likes them as individuals and is “on their side”.

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”. All four elements of the doctor-patient relationship impact patient satisfaction.

·  Trust: Bennett et al found that, among patients with systemic lupus erythematosus, those who trust and “like” their physician had higher levels of satisfaction. In another study, patients’ perceptions of their physician’s trustworthiness were the drivers of patient satisfaction.

·  Knowledge: When doctors discovered patient concerns and addressed patient expectations, patient satisfaction increased as it did when doctors allowed a patient to give information.

·  Regard: Ratings of a physician’s friendliness, warmth, emotional support, and caring have been associated with patient satisfaction.

·  Loyalty: Patients feel more satisfied when doctors offer continued support; continuity of care improves patient satisfaction.

The following factors can interfere with the doctor-patient relationship.

·  Patient factors: New patient, poor prognosis, afflicted with a frustrating disease (which is difficult to treat), difficult patient, health literacy, turbulent society.

·  Provider factors: Physician burnout (state of detachment, emotional exhaustion, and lack of work-related fulfilment), doctors in training or in early career, Conflict on or with the treatment team, poor communication skills, increased specialization.

·  Patient/Provider mismatches: Language barriers, cultural barriers, locus of control (power struggle).

·  Systemic factors: Time constraints, space/room (lack of/inadequate privacy), high patient-provider ratio, urgent care setting (e.g., emergency department, clinic), cost, documentation burden.

Different forms of doctor-patient relationship arise from differences in the relative power and control exercised by doctors and patients. In reality, these different models perhaps do not exist in pure form, but nevertheless most consultations tend towards one type.

·  Paternalistic relationship: A paternalistic (or guidance-cooperation) relationship, involving high physician control and low patient control, where the doctor is dominant and acts as a ‘parent’ figure who decides what he or she believes to be in the patient’s best interest. This form of relationship traditionally characterized medical consultations and, at some stages of illness, patients derive considerable comfort from being able to rely on the doctor in this way and being relieved of burdens of worry and decision-making. However, medical consultations are now increasingly characterized by greater patient control and relationships based on mutuality.

·  Mutuality relationship: A relationship of mutuality is characterized by the active involvement of patients as more equal partners in the consultation and has been described as a ‘meeting between experts’, in which both parties participate as a joint venture and engage in an exchange of ideas and sharing of belief systems. The doctor brings his or her clinical skills and knowledge to the consultation in terms of diagnostic techniques, knowledge of the causes of disease, prognosis, treatment options and preventive strategies, and patients bring their own expertise in terms of their experiences and explanations of their illness, and knowledge of their particular social circumstances, attitudes to risk, values and preferences.

·  Consumerist relationship: A consumerist relationship describes a situation in which power relationships are reversed; with the patient taking the active role and the doctor adopting a fairly passive role, acceding to the patient’s requests for a second opinion, referral to hospital, a sick note, and so on.

·  Default relationship: A relationship of default can occur if patients continue to adopt a passive role even when the doctor reduces some of his or her control, with the consultation therefore lacking sufficient direction. This can arise if patients are not aware of alternatives to a passive patient role or are timid in adopting a more participative relationship.

Not only has medicine undergone tremendous advancements over the years, the social milieu has changed and the patients have changed as well, which is reflected in the doctor-patient relationship; from “paternalism”, where doctors were “parent figures” taking medical decisions on behalf of their patients to the current “patient-centric” where the patient is an “equal partner”.

Nevertheless, the different types of relationship, and particularly those characterized by paternalism and mutuality, can be viewed as appropriate to different conditions and stages of illness. For example, in emergency situations it is generally necessary for the doctor to be dominant, whereas in other situations patients can be more actively involved in treatment choices and other decisions regarding their care.

Regardless of experience and skill, it is inevitable that, at some point in a doctor’s career, the doctor-patient relationship will break down. There can be many reasons for this; sometimes, these are beyond the control of the clinician, but often conflict arises when there is a genuine or perceived failure of the doctor to meet one or more of his/her duties. It is important to recognize a breakdown in the relationship quickly and, whenever possible, identify the reason. If patients are unhappy with an aspect of their care, they are entitled to a prompt, open, constructive, and honest response that includes an explanation and, if appropriate, an apology. It is also important to reassure the patient that the issues raised will not adversely affect their future care. Often, an acknowledgment that something is wrong and demonstration of a desire to put things right are sufficient to rectify any conflict. However, the longer one takes to address a problem, the more difficult it becomes to resolve. The patient may continue to be dissatisfied with the doctor and it may be most appropriate for another colleague to take over their care.

Another contemporary effect on the doctor-patient relationship has been the exponential increase in the use of the internet by the patients. This means that the patients are better informed, especially in the more affluent society, and this has facilitated the patient-centered approach to health care that predominates today. While better patient education has obvious advantages for the doctor-patient relationship, there are concerns that information on the internet might not always be accurate and reliable. This poses a new challenge for the medical professional – that of revising any misinformation the patient has found himself or herself.

It is patients right to know about his disease and management plan. However, most patients expect cure & of the disease and relate outcome to doctors competence and efforts. They do not understand limitations of medical science and that of a doctor who cannot cure every disease even with best of competence and intentions. Earlier generation of patients had full faith in their doctors and they were satisfied with doctor’s best efforts irrespective of the outcome. Lack of faith in doctors of present generation of patients is the cause of poor doctor-patient relationship.

Effective communication between doctor and patient is a central clinical function that cannot be delegated. Most of the essential diagnostic information arises from the interview, and the doctor’s interpersonal skills also largely determine the patient’s satisfaction and positively influence health outcomes. Such skills, including active listening are qualities of a doctor most desired by patients. There is considerable healing power in the doctor-patient alliance. The bond of trust between the patient and the doctor is vital to the diagnostic and therapeutic process. It forms the basis for the doctor-patient relationship.

The primary objective of the doctor is to listen to the patient in order to identify what is the ‘real’ problem actually is instead of simply eliciting symptoms and signs. Shared decision-making between the doctor and the patient will determine the most appropriate and best course of action for an individual patient.

Unethical practices by doctors and unrealistic expectations leading to irrational behavior of patients have resulted in erosion of faith, trust, and mutual respects for each other. Present generation of doctors practice defensive medicine that demands large number of tests and interventions with increase in cost of health care. It is a known fact that error of commission is more acceptable and condoned than error of omission that is punished.

Doctors look at every patient as a potential litigant while patients look at the doctor as one who would cheat. This kind of behavior on the part of patients has led to increase in number of legal suits against the doctors and hence doctors justify defensive medicine. Besides doctors have to face danger to their own life and property.

Hence, present generation of doctors have to spend for professional indemnity insurance against such possible events and such extra expenses are indirectly borne by patients. It has further vitiated doctor-patient relationship with disadvantage to both the parties.