Regressing or progressing: what next for the doctor–patient relationship?

Abstract

Looking at the doctor–patient relationship over the past few centuries, there has arguably never been a better time to be a patient. The physician-charlatans depicted by Molière 300 years ago who were interested solely in money and power would find no place in today's health-care systems, which adhere to principles of reduced physician dominance and shared decision making. However, despite having entered a patient-centric era of medicine, in a 2015 textbook introducing the medical humanities, Thomas Cole and authors remarked that the doctor–patient relationship “is in trouble on both sides of the hyphen”, with clinical encounters often being hurried, increasingly mediated by technology, and set in impersonal hospital settings. Indeed, with treatment algorithms and genetic medicine already transforming medical decision making, there are concerns that the digital era will mean patients once again are being forced to take a backseat in their treatment as power is shifted into the hands of the treatment and technology providers, with the disease, not the individual, becoming the focus of care. Exploring the history of the doctor–patient relationship offers a way to delve into these concerns by highlighting the role that technological, socioeconomic, and political factors can play in knowledge ownership and the power dynamic inherent to the provision and receipt of care. Pick up a play or a book from the early modern period (1550–1750), and the chances are that if there's a doctor in it, they will have been portrayed unfavourably. In Renaissance plays, physicians were often included as figures of fun—eg, the drunk surgeon in Shakespeare's Twelfth Night—and were generally held in very low regard. For example, in Macbeth the Scottish doctor admits his inability to cure Lady Macbeth's somnambulism, as he states, “This disease is beyond my practice”. Despite—or perhaps because of—this perceived incompetence of physicians, this era was one in which the patient held great power over the medical profession. At the heart of this power dynamic was medical theory. At the time, learned physicians were educated in the classical Greek theory of the four humours—blood, yellow bile, black bile and phlegm—and of the four qualities hot, cold, wet, and dry that in combination made up the humours. “This meant that everyone was seen to have an individual idiosyncratic humoural balance or temperament and complexion”, explains Andrew Wear, Emeritus Reader in the History of Medicine at University College London (London, UK). “The physicians therefore advertised to patients that they provided individualised treatment”, he adds. With little effective regulation of medicine however, physicians were not just in competition with each other to gain the services of wealthy patients (in the “medical market place”), but also with charlatans and empirics selling drugs and panaceas, uroscopists, medical astrologers, wise women, clergymen, and charitable neighbours practising lay medicine. “This situation meant that the practitioner had to relate to the subjective symptoms of the patient, ‘the patient's story’, if they wanted to be employed by the patient”, explains Wear. Another important external factor in the relationship was the widespread belief in the existence of non-medical sources of illness, which called into question the very need for physicians. This was a time when God or magic were believed by some to be the causes of illness, for which prayer or recourse to a white witch were the cures, not a visit from a doctor. “The existence of this multicausal system meant that the patient very often was initially choosing how to interpret their illness as well as choosing the type of practitioner”, explains Wear. “In other words, the power relationship between patient and doctor was more on the side of the patient, especially as the practitioner, given a lack of convincing medical trials of remedies and treatments, could not convince the public of the efficacy of a drug or treatment”, he adds. This attitude was exemplified by Thomas Hobbes' (1588–1679) who noted of Renaissance doctors that he would “rather have the advice or take physic from an experienced old woman that had been at many sick people's bedsides than from the learned but unexperienced physician”. However, with the rise of hospital medicine in the 18th and especially in the 19th century—ushered in by an era of heroic hospital building in major cities—physicians and surgeons became salaried and the pendulum of power shifted to the doctors, who were no longer beholden to the patient. Although patients who entered the 19th century hospitals were mainly poor, with the well-off continuing to receive treatment at home, by the early 20th century, as medicine became more technology based, serious illness for everyone meant a stay in a hospital—“an alien and often frightening place for a patient where medical staff had more power over the patient than they would in the patient's home”, describes Wear. The 19th century also saw medicine become professionalised, with the state recognising particular types of physician as “registered” doctors. The UK Medical Act of 1858 set up the General Medical Council and the Medical Register, which increased the power and prestige of physicians and surgeons who were now recognised and given the authority to be self-governing in relation to educational standards and matters of discipline. “This again changed the balance in the doctor–patient relationship as the registered practitioner now had more prestige and authority and the patient effectively had less choice because other practitioners seemed to have less authority”, clarifies Wear. He adds that the power of the doctor also increased in the 20th century due to the growth of secularism and the decline in the belief of a God being actively involved in the day-to-day happenings of an individual. With the rise of laboratory medicine in the late 19th and 20th century, medicine moved further away from treating the patient's subjective symptoms and towards treating their disease, a shift Wear classifies as a “depersonalisation” of care. This was facilitated by the introduction of instruments that increasingly professionalised and specialised the medical field and subsequently altered the power balance in the clinic. “From the stethoscope in the early 19th century to modern blood tests and biopsies, the doctor had knowledge, that in a sense was hidden from the patient—and as every sociology student learns today, knowledge is power”, posits Wear. This knowledge imbalance often led to new medical technologies being described as magical, wonderful, and frightful by their first users, as they become focal points of hope, anxiety, dread, and horror within the medical consultation, explains Melissa Dickson, lecturer in Victorian literature at the University of Birmingham (Birmingham, UK). The stethoscope, in the early 19th century, for example, was the subject of poetic treatment in periodicals such as Blackwood's, which referred to the instrument through various metaphors, including a “musician's trumpet”, “a king's scepter”, “a prophet's source of vision”, and “a priest's sacrificial altar”. “Here, and in many stories of the period, the stethoscope emerged as all powerful, all knowing, and entirely indifferent to human desire”, describes Dickson. The medical thermometer too was met with anxiety: in In Search of Lost Time (1920–21), for example, Marcel Proust coined the thermometer a “little sorceress” and an “implacable warder”, suggesting that to be a patient was to throw oneself upon mystical, inaccessible knowledge, which both assisted and entrapped. This general trajectory from subjectivity to scientificity continued into the latter half of the 20th century, subsequently “pushing the doctor–patient relationship to the margins of an all-powerful biomedical framework”, notes Anna Elsner, Swiss National Science Foundation MHV Fellow at the Institute for Biomedical Ethics and History of Medicine (University of Zurich, Zurich, Switzerland). This notion was explored by writer Hervé Guibert in his description of the famous French philosopher Michel Foucault's experience of being treated in hospital for HIV/AIDS in early 1990s France: Foucault “spent a morning in the hospital having tests done, and told me he'd forgotten how completely the body loses all identity once it's delivered into medical hands, becoming just a package of helpless flesh, trundled around here and there, hardly even a number on a slip of paper.” Elsner notes that this example is paradigmatic of the doctor–patient relationship in the latter half of the 20th century, capturing the dehumanising effects of Foucault's concept of the “medical gaze”—the medical separation of the patient's body from the patient's person and identity. “In the foreground is the anonymity of the hospital setting paired with technical descriptions, patronising discourses, and a general distancing from, and disinterest in, the patient's experience of illness”, she explains. In the past 20 years, however, the notion of the medical gaze has been challenged, and today the predominant model in clinical practice includes an active and autonomous role for the patient. In this patient-centric approach, “the physician tries to enter the patient's world, to see the illness through the patient's eyes”, once described Ian McWhinney, the late English physician. Indeed, the end of the 20th century saw a proliferation of autobiographical narratives about illness and the end-of-life, pointing towards a new interest in recovering the patient's voice. Elsner posits that this transition was likely connected to the rise of biomedical ethics after World War 2 and, as a result, the challenging of medical authority and paternalism. Bearing further testimony to this fundamental shift towards patient empowerment have been the establishment of patient advocacy groups, patient-safety organisations, and the idea of health literacy—as of 2009, chronic patients in France can even gain a diploma from the Pierre and Marie Curie University in Paris as a ‘patient expert’. Providing an example of the benefit that raising the patient voice can have on the clinical encounter, Elsner notes the international success of healthtalk.org, a website that shares real-life stories of people living with different conditions, which is used as a resource for medical teaching and training. In the UK, a further factor in the changing power dynamic in the doctor–patient relationship came in the form of the introduction of markets to health care in the 1990s. “Because of the neoliberalist culture in the NHS initially begun by the Thatcher government, where patients became ‘consumers’ and therefore like other consumers of services, could demand more of the service, there tended to be a flatter power balance and a more equal relationship”, explains Jo Brown, Head of Quality in Teaching and Learning at Bart's and the London Medical School (London, UK). This has resulted in a shared decision-making culture whereby doctors do not lead or compel patients in their health decisions, but rather walk alongside the patient as an expert guide. While some have criticised the consumer model for placing too heavy a responsibility on the patient, the notion of shared decision making was recently clarified in UK law by the 2015 Montgomery v Lanarkshire Health Board judgment. In its ruling, the Supreme Court ruled that doctors now have a duty to ensure that patients are aware of any material risks of any recommended treatment and of any reasonable alternative. The decision was touted as a victory for patient autonomy and even as the final nail in the coffin for medical paternalism in the UK. However, despite the clear trend towards greater patient control, perhaps Thomas Cole and authors are right to be concerned. In recent years, doctors' voices and their dissatisfaction within increasingly bureaucratic institutions have been coming to the fore (eg, the writings of Atul Gawande, Seamus O'Mahony, and Haider Warraich). Deploring structural changes in medicine and testifying to an erosion of confidence in the future of the medical profession and the place attributed to the doctor-patient relationship, they echo what the French physician and writer Jean Reverzy has already in the mid-20th century described as the overwhelming “fatigue” of the physician. Elsner notes that while the development of narrative medicine, the further integration of medical humanities courses in the medical curriculum, and the development of subspecialties such as palliative care have been steps taken to advance towards more humanistic clinical care, challenges remain. “In the age of genomic medicine, the role of the physician will gravitate towards technical expertise and will be shaped even more significantly by the need to assist the patient in the information-gathering process. But the role of the patient will undergo a comparably fundamental shift as genetic predispositions rather than an already developed disease will play a role of growing importance”, she predicts. Furthermore, as the use of smart technology grows among the general population, some predict an accompanying blurring of medical and everyday devices, which will have wide-reaching political implications. “While private tech companies are hardly new players in the medical sector, the presence of multinational, corporate firms at an intimate bodily level on a day-to-day basis implies a fundamental shift in what we mean by the ‘doctor–patient relationship’”, notes Harriet Barratt, doctoral researcher in medical humanities, University of Sussex, UK. As monitoring and treatment patterns shift, who will count as a patient and who will count as a provider of care? More than ever, Barratt notes, patients are likely to end up navigating an array of state, third sector and private providers of treatment and technology, whose influence will continue to transform the role of the traditional family or hospital doctor. Furthermore, as the introduction of apps and genomic medicine inserts more distance (both physical and emotional) between doctor and patient, will there once again be a backlash against the scientificity-over-subjectivity approach and a return to listening to the patient's story? What is certain is that the doctor–patient relationship, and its inherent reliance on technology and innovation, particularly in terms of concerns around privatisation and the use of personal data, will be inextricable from the politics of 21st century health care. For more on the depiction of physicians in Molière's plays see Mak N. Physician culture and identity: the portrait of medicine in Molière. Intima Spring 2015For Thomas Cole and authors' textbook see Cole TR, Carlin N, Carson RA. Medical humanities: an introduction. Cambridge: Cambridge University Press, 2015For Hervé Guibert ‘s novel see Guibert H. To the Friend Who Did Not Save My Life. London: Quartet Books, 1991To find out more about healthtalk.org see http://healthtalk.org/To read Jean Reverzy's novel on physician fatigue see Reverzy J. Place des angoisses. Julliard, 1954 For more on the depiction of physicians in Molière's plays see Mak N. Physician culture and identity: the portrait of medicine in Molière. Intima Spring 2015 For Thomas Cole and authors' textbook see Cole TR, Carlin N, Carson RA. Medical humanities: an introduction. Cambridge: Cambridge University Press, 2015 For Hervé Guibert ‘s novel see Guibert H. To the Friend Who Did Not Save My Life. London: Quartet Books, 1991 To find out more about healthtalk.org see http://healthtalk.org/ To read Jean Reverzy's novel on physician fatigue see Reverzy J. Place des angoisses. Julliard, 1954