A love letter to the patient-doctor relationship

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This is a love letter. It is an ode to clinical psychiatry from one psychiatrist to another, to all those who see patients in the hospital, whether they are in consultation teams, in the emergency room, in individual practice, or on small screens scattered across the country. All of us, psychiatrists, mental health clinicians and therapists, listen to stories, absorb emotions, and offer comfort and positive action to patients and families. Together, we promote healing and recovery.

Why would someone write a love letter to their specialty? Because after 2 decades of practicing medicine, I still find the intricacies of the human mind fascinating; I have the greatest respect for my field, which perfectly combines art and science. Scientific advances in psychiatry are rapid and complex, and revolutions in the conceptualization of mental illness are underway. Yet none of these advancements or treatments can be meaningfully implemented without a thorough history, an understanding of the patient’s environment and family dynamics, and an assessment of their understanding of the symptoms and their readiness to recover. ‘initiate treatment. Most importantly, neither can be implemented without the trust and connectivity that exists in a healthy patient-physician relationship.

The art of medical conversation

The art of psychiatry dates back to the patient-physician relationship, the cornerstone of medicine, as it has been for millennia. This relationship has evolved, of course, reflecting changes in our understanding of disease, well-being, and the roles of patients and physicians. Over the centuries, the physician has evolved from a healer with almost magical powers to a partner in well-being and recovery. This development has been evident throughout history, but it is only recently that scientific attention has turned to exactly what the doctors are doing that have such a big impact.

In his flagship work of 1932, The doctor, his patient and the disease, Michael Balint, MD, PhD,1 invented the concept of the doctor as a medicine. He stressed the importance of the therapeutic interaction, calling it vital for treatment while acknowledging that the dose of this treatment – the number of visits required and the length of visits – was not clear. Subsequent literature developed new terminology. Traditional medicine called it the “patient-doctor relationship”, while the psychiatric field would call it non-specific factors. Whatever the terminology, it is the I do not know what which takes place in the privacy of a real conversation between human beings.

What happens when we lose contact

Up to 40% of deaths are attributable to modifiable behavioral factors (such as a healthy diet, substance use and physical activity).2.3 Whether or not patients change these behaviors depends to a large extent on the level of trust they place in their physicians.4 Qualities such as availability, caring, compassion, competence, honesty, integrity, knowledge, reliability, respect, sincerity and understanding are cited as essential to foster and maintain a patient relationship. healthy doctor.5

However, the realities of modern healthcare do not fit and protect this relationship growth paradigm as well. Over the past decades, the foundations of clinical medicine / psychiatry have come under attack from the healthcare system itself. The duration of visits has decreased significantly,6 as is the number of psychiatrists providing therapy.7 We must therefore ask ourselves the question: in a visit of 10 to 15 minutes, how far can we really build a therapeutic alliance? I’m afraid our self-concept will change too. Words like provider, prescriber, and mental health specialist do not reflect the centrality of the patient-physician relationship. We risk losing the sense that, in the words of Hugh Crichton-Miller, MD, “the patient [is] not just an object but a person, needing to be enlightened and reassured.8

The health care system has attempted to normalize those aspects of the patient-physician relationship that might promote success. Bias and countertransference are 2 aspects that were studied in the context of meetings with patients,9-12 and it is recognized that alignment in the patient-physician relationship is a desirable asset for successful therapeutic alliances.13.14 Achieving this concordance in short and scattered clinical visits may not be achievable, but operationalizing these concepts nonetheless leads to a better understanding of non-specific factors in the patient-physician relationship.

When doctors and patients are unable to build strong relationships, patients fare less well. In the treatment of depression, the number of meetings with the therapist or doctor, regardless of the treatment modality, affects the results, even when patients are treated with psychotropic agents.15 The working alliance becomes even more important when it comes to tackling difficult issues of trauma and addiction.16 Recent advances inform us that non-specific factors in treatment can be conceptualized in 2 areas: expectation and alliance. These can be subdivided into trait-type and state-type dimensions, each with its own neurobiological underpinnings.17 Trait-like components refer to attachment and personality styles, and they influence the relationship between the patient and the person treating them in non-specific ways.15 When used optimally and at the right time, state-like dimensions can be used as active ingredients for therapy change. Technological advances make it possible to study the therapeutic alliance as it evolves session by session, taking into account intra-individual fluctuations and stable inter-individual differences.18

The therapeutic alliance is also crucial in overcoming the stigma associated with mental health. Individuals are sometimes unhappy with psychiatric labels, and some patients may be harassed for using mental health care. To bridge this gap, we turn to the art of psychiatry, the alliance in the patient-physician relationship that helps patients see their treatment as a way to achieve their life goals and to recover.

Concluding thoughts

The patient-doctor relationship is what the future Psychiatric schedulesMT series, “Tales of The Clinic: The Art of Psychiatry,” is all about. The cases discussed are fictitious, but they represent current presentations. Moving on from the case, human history, we turn to the evidence-based application of psychiatric research, highlighting the complex interplay of art and science. As readers will note, some cases span years of treatment. Many patients will say that they never thought that their improvements were possible and that the treatment gave them new life. But progress is not possible without the art and the science, the art of the human relation and the science which brings us effective and precise treatments.

So, to all my fellow psychiatrists and therapists, this is a love letter to our wonderful field, where the magic of medicine is still alive. Your comments on these cases are welcome. Please send them to [email protected]

Dr Moukaddam is Associate Professor, Menninger Department of Psychiatry and Behavioral Sciences, Baylor College of Medicine, and Ben Taub Adult Outpatient Services Director, Medical Director, Stabilization, Treatment and Rehabilitation (STAR) Program for Psychosis. She also sits at Psychiatric schedulesMT Advisory board.

The references

1. Balint M. The doctor, his patient and disease. The Lancet. 1955; 265 (6866): 683-688.

2. Danaei G, Ding EL, Mozaffarian D, et al. Preventable Causes of Death in the United States: A Comparative Assessment of Diet, Lifestyle, and Metabolic Risk Factors. PLoS Med. 2009; 6 (4): e1000058.

3. Mokdad AH, Marks JS, Stroup DF, Gerberding JL. Actual causes of death in the United States, 2000. JAMA. 2004; 291 (10): 1238-1245.

4. Berry LL, Parish JT, Janakiraman R, et al. Patients’ commitment to their treating physician and why it matters. Ann Fam Med. 2008; 6 (1): 6-13.

5. Tune SB. Are there plans to build a strong patient-doctor relationship? Virtual mentor. 2009; 11 (3): 232-236.

6. Gottschalk A, Flocke SA. Time spent on face-to-face care and work outside of the exam room. Ann Fam Med. 2005; 3 (6): 488-493.

7. Olfson M, Marcus SC, Druss B, et al. National trends in outpatient treatment of depression. JAMA. 2002; 287 (2): 203-209.

8. Crichton-Miller H. The doctor’s personality: the doctor’s role in society. Hogarth Press; 1932.

9. Dehon E, Weiss N, Jones J, et al. A systematic review of the impact of implicit racial biases of physicians on clinical decision-making. Acad Emerg Med. 2017; 24 (8): 895-904.

10. Dovidio JF, Penner LA, Albrecht TL,. Disparities and mistrust: the implications of psychological processes for understanding racial disparities in health and healthcare. Soc Sci Med. 2008; 67 (3): 478-486.

11. Hirsh AT, Hollingshead NA, Ashburn-Nardo L, Kroenke K. The interplay of patient race, provider bias, and clinical ambiguity on pain management decisions. J Pain. 2015; 16 (6): 558-568.

12. Johnson TJ, Winger DG, Hickey RW, et al. Comparison of implicit racial biases of physicians towards adults versus children. Acad Pediatrics. 2017; 17 (2): 120-126.

13. Schinkel S, Schouten BC, Street RL Jr, et al. Improving Health Communication Outcomes in Ethnic Minority Patients: The Effects of Matching Preferences and Perceptions of Participation and Doctor-Patient Matching. J Common Health. 2016; 21 (12): 1251-1259.

14. Street RL Jr, Gordon H, Haidet P. Physician Communication and Patient Perceptions: Is It What They Look Like, How They Speak Or Is It Just The Doctor? Soc Sci Med. 2007; 65 (3): 586-598.

15. Falkenström F, Josefsson A, Berggren T, Holmqvist R. How much therapy is sufficient? compare dose-response models and good enough in two different settings. Psychotherapy (Chic). 2016; 53 (1): 130-139.

16. Wang LP, Maxwell SE. On the disaggregation of inter-individual and intra-individual effects with longitudinal data using multilevel models. Psychological methods. 2015; 20 (1): 63-83.

17. Zilcha-Mano S, Roose SP, Brown PJ, Rutherford BR. Not just nonspecific factors: the roles of alliance and expectation in treatment, and their neurobiological foundations. Behavioral neurosci before. 2019; 12: 293.

18. Falkenström F, Solomonov N, Rubel J. Using analysis of time-shifted panel data to study the mechanisms of change in psychotherapy research: methodological recommendations. Psychother Res Accounts. 2020; 20 (3): 435-441. ??

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