Virtual physicians, health systems, and the healing relationship.

Abstract

Healing relationships are characterized by several enduring features: the patient is and feels known as a unique sentient being; the patient is provided with good information, prudent judgment, and presence; and the patient is involved actively in his or her own health care. But healing relationships are complex. First, healing relationships include more than just the physician-patient dyad. Consider the situation of a man recently diagnosed with prostate cancer. His healing relationships might include several physicians, who may or may not constitute a team, and with whom he might communicate in person, over the telephone, or via e-mail; other health professionals, both mainstream and “complementary/alternative”; his close friends and family; someone he happened to meet on an airplane; acquaintances from a web chat room; or an imagined or spiritual being.1 Second, the nature of information provided is different, depending on which city or country he lives in, and on whether his primary care physician refers him first to a urologist or a radiation oncologist. Third, the patient may welcome or may be overwhelmed by attempts to involve him in his health care, such as providing a menu of treatment options. Fourth is the issue of continuity; when his primary physician is on vacation, or leaves the practice, he entrusts the relationship to someone who otherwise might be a stranger. But the relationship does not start anew; continuity of context and information, and an implicit relationship between the new physician and the prior physician ease the transition. The set of articles in this issue of the Journal of General Internal Medicine may initially seem unrelated. However, they are all linked by the theme of elements extrinsic to the physician-as-person, which may be included, in the patient's view, within the healing relationship. These elements include the culture, the health care system, the office setting, the medium of communication, the patient's hopes, and continuity. Even as blunt an instrument as a governmental mandate can, as Baker et al.2 show, swiftly and irreversibly change the nature of emotionally charged patient-physician discussions. A statistician might think of these elements as confounders that impinge on what is and should be a dyadic relationship. For example, some internists dread the presence of family members at an office visit and view them as barriers to effective communication and patient care.3,4 But I doubt that most patients take a similar view (there are exceptions, of course!). Taking the patient's view, these “confounders” constitute part of the web of influences that the patient receives and cannot distinguish from the physical presence of the physician. These may be core elements of the patient-physician relationship.