Clinician–Patient Relationship

Overview

Definitions

• Relationship: a connection, association, or involvement between 2 or more parties
• Physician: a licensed medical doctor 
• Clinician: a physician, nurse practitioner, physician assistant, or another health professional who is directly involved in patient care and has a professional relationship with patients.
• Patient: a person receiving medical care Medical care Conflict of Interest 
• Fiduciary: a person to whom power is entrusted for the benefit of another in situations in which an individual lacks decision-making capacity Decision-making capacity Decision-making capacity describes a patient’s ability to make autonomous decisions regarding their care, as determined by a physician. Decision-making Capacity and Legal Competence regarding their care.

Characteristics of a clinician–patient relationship

• Empathy Empathy An individual’s objective and insightful awareness of the feelings and behavior of another person. It should be distinguished from sympathy, which is usually nonobjective and noncritical. It includes caring, which is the demonstration of an awareness of and a concern for the good of others. Psychotherapy: the psychological identification Identification Defense Mechanisms with or vicarious experiencing of the feelings, thoughts, or attitudes of another person; considered a quintessential virtue of a physician
• Compassion: a feeling of sympathy or sorrow for another, accompanied by a strong desire to alleviate their suffering
• Humanizing: The patient is understood to be a human being in distress due to the disease process.
  • Describe patients as people, not medical conditions. Example: “ Mr MR Calculated as the ratio of the total number of people who die due to all causes over a specific time period to the total number of people in the selected population. Measures of Health Status. M. is the patient with appendicitis Appendicitis Appendicitis is the acute inflammation of the vermiform appendix and the most common abdominal surgical emergency globally. The condition has a lifetime risk of 8%. Characteristic features include periumbilical abdominal pain that migrates to the right lower quadrant, fever, anorexia, nausea, and vomiting. Appendicitis in room 12,” not “That’s the appendix Appendix A worm-like blind tube extension from the cecum. Colon, Cecum, and Appendix: Anatomy that just came in.” 
  • Use nonstigmatizing and patient-focused language. Examples: “people who use injection drugs,” not “IV drug users,” and “patient-directed discharge” versus leaving “against medical advice.”
• Confidence and trust Trust Confidence in or reliance on a person or thing. Conflict of Interest: Physicians communicate that they are professional and trustworthy and will listen to and address the patient’s complaints.
  • Verbal cues: attentiveness to and genuine interest in the patient’s recollection of their medical history
  • Nonverbal cues: professional conduct and appearance 
• Reassurance: the patient’s emotions, feelings, and concerns are validated and addressed.
• Mutual consent: certain circumstances may create a limited relationship without the patient’s explicit agreement:
  • Emergency care: the patient’s agreement to the relationship is implicit.
  • Court-ordered medical care Medical care Conflict of Interest for a prisoner: in keeping with ethics Ethics Medical ethics are a set of moral values that guide the decision-making of health care professionals in their daily practice. A sense of ethical responsibility has accompanied the profession of medicine since antiquity, and the Hippocratic oath was the 1st document to codify its core ethical principles. Medical Ethics: Basic Principles guidance on court-initiated treatment

Beginning and ending relationships

• Beginning a clinician–patient relationship requires 2 elements:
  • A patient who requests the aid of a clinician.
  • A clinician who accepts the patient’s request to provide care.
• The relationship can be ended by the physician or the patient when:
  • The former chooses not to provide care, except for vital emergencies.
  • The patient chooses not to be under the care of that physician.
  • Termination of a clinician–patient relationship by the clinician must be made via written communication Communication The exchange or transmission of ideas, attitudes, or beliefs between individuals or groups. Decision-making Capacity and Legal Competence with a reasonable amount of notice (typically 30 days).

Physician Responsibilities and Rights

The duties of a physician in the clinician–patient relationship go hand Hand The hand constitutes the distal part of the upper limb and provides the fine, precise movements needed in activities of daily living. It consists of 5 metacarpal bones and 14 phalanges, as well as numerous muscles innervated by the median and ulnar nerves. Hand: Anatomy in hand Hand The hand constitutes the distal part of the upper limb and provides the fine, precise movements needed in activities of daily living. It consists of 5 metacarpal bones and 14 phalanges, as well as numerous muscles innervated by the median and ulnar nerves. Hand: Anatomy with the code of ethics Ethics Medical ethics are a set of moral values that guide the decision-making of health care professionals in their daily practice. A sense of ethical responsibility has accompanied the profession of medicine since antiquity, and the Hippocratic oath was the 1st document to codify its core ethical principles. Medical Ethics: Basic Principles.

Clinician’s responsibility

• To provide competent medical care Medical care Conflict of Interest 
• To follow the basic principles of medical ethics Ethics Medical ethics are a set of moral values that guide the decision-making of health care professionals in their daily practice. A sense of ethical responsibility has accompanied the profession of medicine since antiquity, and the Hippocratic oath was the 1st document to codify its core ethical principles. Medical Ethics: Basic Principles: beneficence Beneficence The state or quality of being kind, charitable, or beneficial. The ethical principle of beneficence requires producing net benefit over harm. Medical Ethics: Basic Principles, nonmaleficence Nonmaleficence Not acting with the intention to do harm. Medical Ethics: Basic Principles, autonomy Autonomy Respect for the patient’s right to self-rule. Medical Ethics: Basic Principles, and justice Justice An interactive process whereby members of a community are concerned for the equality and rights of all. Research Ethics 
• To act in the patient’s best interests, using medical knowledge and expertise to resolve a patient’s symptoms or providing a solution that helps achieve the greatest quality Quality Activities and programs intended to assure or improve the quality of care in either a defined medical setting or a program. The concept includes the assessment or evaluation of the quality of care; identification of problems or shortcomings in the delivery of care; designing activities to overcome these deficiencies; and follow-up monitoring to ensure effectiveness of corrective steps. Quality Measurement and Improvement of life in a particular situation (including near the end of life)
• To protect the patient’s privacy by keeping all information confidential
• To disclose information to the parties involved when necessary, including bad news Bad news Bad news is broadly defined as any information that may alter a patient’s view of their future. Bad news is typically life-changing information that should be communicated to the patient and family with empathy and honesty. Delivery of Bad News
• To obtain informed consent Informed consent Informed consent is a medicolegal term describing the documented conversation between a patient and their physician wherein the physician discloses all relevant and necessary information to a patient who is competent to make an informed and voluntary decision regarding their care. Competency, disclosure, and voluntariness are the key elements upon which IC is based. Informed Consent for all procedures
• To avoid conflicts of interest Conflicts of interest A situation in which an individual might benefit personally from official or professional actions. It includes a conflict between a person’s private interests and official responsibilities in a position of trust. The term is not restricted to government officials. The concept refers both to actual conflict of interest and the appearance or perception of conflict. Medical Ethics: Basic Principles that may compromise the patient’s well-being and outcomes 
• To respect all decisions made by a competent patient or their fiduciary
• To represent the interests of the sick and injured against societal demands
• To honor advance directives Advance Directives The term advance directive (AD) refers to treatment preferences and/or the designation of a surrogate decision-maker in the event that a person becomes unable to make medical decisions on their own behalf. Advance directives represent the ethical principle of autonomy and may take the form of a living will, health care proxy, durable power of attorney for health care (DPAHC), and/or a physician’s order for life-sustaining treatment (POLST). Advance Directives of the patient

Clinicians’ rights

• To refuse to provide care
• To be treated with respect as a professional
• To be granted the professional freedom to care for patients without interference, using their experience and the best evidence available
• To exercise professional judgment Judgment The process of discovering or asserting an objective or intrinsic relation between two objects or concepts; a faculty or power that enables a person to make judgments; the process of bringing to light and asserting the implicit meaning of a concept; a critical evaluation of a person or situation. Psychiatric Assessment and discretion
• To have the independence to represent and defend the health needs of patients against all who might deny or restrict access
• To be compensated fully and fairly for their services

Patient Rights and Responsibilities

Patient rights are a subset of human rights. They include minimum standards for the ways patients can expect to be treated by clinicians, and behind each is an ethical principle.

Patients’ rights

• To courtesy, respect, dignity, and timely, responsive attention Attention Focusing on certain aspects of current experience to the exclusion of others. It is the act of heeding or taking notice or concentrating. Psychiatric Assessment to their needs
• To receive information from their physicians and have an opportunity to discuss the benefits, risks, and costs of appropriate treatment alternatives
• To ask questions about their health status or recommended treatment when they do not fully understand what has been described and to have their questions answered
• To make decisions about the care the physician recommends and to have those decisions respected 
• To have the physician and other staff respect the patient’s privacy and confidentiality Confidentiality Confidentiality is a set of rules that dictates the protection of health information shared by a patient with a physician. In general, this information should only be used to dictate medical decision-making steps and can only be disclosed to a 3rd party with the patient’s express consent. Patient-Doctor Confidentiality
• To obtain copies or summaries of their medical records
• To obtain a second opinion
• To be advised of any conflicts of interest Conflicts of interest A situation in which an individual might benefit personally from official or professional actions. It includes a conflict between a person’s private interests and official responsibilities in a position of trust. The term is not restricted to government officials. The concept refers both to actual conflict of interest and the appearance or perception of conflict. Medical Ethics: Basic Principles their physician may have with respect to their care
• To continuity of care

Patients’ responsibilities

• To provide physicians with a complete and truthful medical history, including past illnesses, medications, hospitalization Hospitalization The confinement of a patient in a hospital. Delirium, family history Family History Adult Health Maintenance of illness, and other matters relating to present health
• To cooperate with agreed-on treatment plans
• To meet their financial responsibilities for medical care Medical care Conflict of Interest or discuss financial hardships with their physician
• To recognize that a healthy lifestyle can often prevent or mitigate illness and take responsibility to follow preventive measures and adopt healthy behaviors
• To refrain from placing others at an unreasonable risk of contracting an illness, infectious or otherwise
• To refrain from being disruptive in the clinical setting
• To not initiate or participate in medical fraud (e.g., falsification of medical records)
• To report illegal or unethical behavior by health care professionals
• To provide the physician with advance directives Advance Directives The term advance directive (AD) refers to treatment preferences and/or the designation of a surrogate decision-maker in the event that a person becomes unable to make medical decisions on their own behalf. Advance directives represent the ethical principle of autonomy and may take the form of a living will, health care proxy, durable power of attorney for health care (DPAHC), and/or a physician’s order for life-sustaining treatment (POLST). Advance Directives that represent their wishes with regard to their death

Obstacles

There may be obstacles to a good clinician–patient relationship that are difficult to overcome or beyond the control of the parties involved. Identifying these is the first step to overcoming them.

Obstacles related to the physician

• Long working hours, job-related stress
• Compassion fatigue Fatigue The state of weariness following a period of exertion, mental or physical, characterized by a decreased capacity for work and reduced efficiency to respond to stimuli. Fibromyalgia
• Excessive reliance on technological advances and computerization
• Secondary interests not in benefit to the patient (e.g., financial or research-related motives)
• Lack of cultural competency/training

Obstacles related to the patient

• Mistrust, dishonesty 
• Noncompliance and nonadherence to treatment plans
• Disrespect and mistreatment of clinicians and other members of the health care team
• Not being forthcoming about lack of comprehension due to language barrier or level of education

Obstacles related to the medical institution and health care system

• For-profit model of health care
• Reduced patient choices regarding institutions and professionals

Boundaries in the Clinician–Patient Relationship

Sexual relationships

• Between a physician and a patient are considered unethical
• Can place the patient or the physician in a vulnerable position
• Can impair the clinician’s ability to make objective decisions
• Contact that could lead to an intimate relationship or that could be misinterpreted by a patient as such can be avoided by:
  • Having a chaperone/staff member who is the same sex Sex The totality of characteristics of reproductive structure, functions, phenotype, and genotype, differentiating the male from the female organism. Gender Dysphoria as the patient present during the physical examination
  • Terminating the clinician–patient relationship if a patient’s behavior compromises the integrity of the physician’s practice of their profession (e.g., improper or lewd comments, flirting, explicit sexual advances) 
• The doctor–patient relationship must be terminated before a romantic relationship can be initiated.

Family ties to patients

• Clinicians should avoid professional relationships with their family members, since objective decision-making may be compromised.
• Care of a family member or close friends should be relinquished to a colleague.

Receiving gifts

• A gift is an expression of gratitude by the patient, usually given after care has been provided. 
• The physician needs to be sensible and accepting of cultural practices while being mindful of the proportionality of the gift. 
• A clinician must not accept a gift if:
  • It is disproportionately large.
  • The physician feels uncomfortable receiving the gift.
  • The gift signifies a significant financial burden for the patient and/or their family.
• When a gift cannot be accepted, the physician must politely explain the reason.
• Examples of acceptable gifts:
  • Mementos made by patients (e.g., drawings made by a patient’s children)
  • Sweets (e.g., boxes of cookies, gift baskets)
  • Culturally significant gestures (e.g., Indigenous populations in Venezuela make decorative, colorful braiding to attach to the tubing of rural physicians’ stethoscopes as an expression of their gratitude.)
• Examples of unacceptable gifts:
  • Large sums of money
  • Properties 
  • Cars/other vehicles

Funerals

• Appropriateness depends on the cultural context.
• A physician may choose to attend a patient’s funeral as a guest to provide comfort to the family.