The patient-physician relationship is at once constant and dynamic.  Nearly a decade and a half ago, I described this interaction as a “covenant of caring – one individual with a need and the willingness to trust and another with knowledge and the desire to respond”.  The AMA has called it a moral enterprise grounded in a “covenant of trust”.  Yet at the same time, this relationship must accommodate changing needs, perceptions, and expectations.  Today, the patient-physician relationship is as much involved with advanced technology, innovative medical treatments, and high tech diagnostic tools as it is the delicate interaction of two human beings.

There are 734.5 million doctors visits in the United States each year, or 2.8 visits for every man, woman, and child in the country. Of the U.S. population, 75% visit a doctor in any given year and 90% do so in any given 3-year period.  This relationship has transcended time; place; and ethnic, social, and political origin; but changed it has and change it must as a human living entity.  The explosion of science and technology, appearance of a health consumer movement, issues of financing, emergence of the Internet, and globalization of healthcare are simply a few of the modern forces at work day to day shaping this uniquely human interaction.

The result of a successful encounter would be defined by sociologists as the accumulation of social capital, that being the value that accrues between two individuals who share a relationship marked by commitment, trust, and a willingness to give at a higher level.  How important is this relationship to society overall?  A recent study suggests more important than we give it credit.  In fact, second only to family relationships, the patient-physician relationship is viewed as extremely or very important by 67% of those surveyed, exceeding relationships with spiritual advisors (52%), pharmacists (45%), co-workers (44%), and financial advisors  (36%).  Efficient and useful patient-physician relationships, as with other societal relationships such as marriage and employee relations, evolve and expand over time as the parties gain and apply their knowledge of each other.  Thus, healthcare systems that constantly rechannel patients to new physicians inadvertently relinquish valuable embedded social capital and ensure a less efficient and more cumbersome form of care.  Once a relationship is established, everything possible should be done to preserve it.

If it is clear that the relationship is dynamic and evolving it is equally clear that patients’ expectations are rising.  They believe the relationship can and should deliver clinical care as well as educational support for informed disease prevention and health economic decision making .  To accomplish these goals, the physician must embrace and coordinate all of the available human resources.  These resources include not only traditionally skilled personnel, such as medical specialists, nurse practitioners, physicians assistants, and pharmacists, but also an array of engaged community based citizens, such as medical librarians, elder care specialists, Alzheimer Day Centers, hospice, visiting nurse associations, voluntary health associations, hospital business departments, Internet Web site managers and more.  Just as physicians have developed comfort and expertise in constructing teams of specialists that are accessible and responsive clinically, so now they must also construct personalized educational team continuums.  For example, the physician treating a patient with diabetes should have a reliable team continuum to support diabetes general education, nutritional counseling, instruction in self-treatment, self-help groups for emotional support, ongoing consumer research, and financial planning.  Without such well-planned and integrated resources, it is likely that the physician’s limited time for engagement in relationship building will continue to be compromised and that the patient’s legitimate expectations for physician leadership will not be met.

These new partnership relationships between patients and physicians are being consummated by patient education.  Increasingly, information is being front-loaded before the office visit.  This is as much the result of changes in information technology as it is a rethinking of health philosophy and the increasing pace of modern society.  Key health information sources used by patients include books (72%), family and friends (69%), television (60%), and the Internet (18% and rising).  But when asked where they turn to ensure that the information they have received is accurate, 89% turn to their physicians.

Where modern empowered patients turn for their information is only one of the pillars of constructive health behavioral change.  While source is important, one must also consider a patient’s trust in the information and their willingness to act upon the information.  A recent national study revealed, when all three elements were considered, that physician provided information was more likely to deliver desired patient action than was information from pharmacist and family and far more likely to deliver desired patient action than was information from news media, Internet, FDA or other patients.

As the patient-physician relationship has evolved first through emancipation, and then through empowerment of education, the expectations for full engagement have been raised in both patient and physician.  It is now well recognized that meaningful dynamic relationships require unimpeded bidirectional access.  This is as true for the patient-physician relationship as it is for a relationship with a spouse, spiritual advisor, financial consultant, or co-worker.  It had been seen in the last decade how low a tolerance both physicians and patients have for systems that impede live encounters.  Whether it be recorded telephone access trees, prior approval programs, physician disappearance from approved provider panels, or busy understaffed medical offices, the inability to consummate the relationship generates militancy on the part of those who deliver and those who receive care.  Thus, the foundation of the current patient rights movement has been access and is the culmination of the second wave of development of the health consumer movement.

What these constituencies have begun to realize, as we enter the third wave of the relationship-based care movement, is that accomplishing physical access to each other can be a hollow victory.  This is because ensuring face-to-face patient-physician encounters on a schedule that both parties agree is responsive and independent of perceived or real third-party interference means very little, save for the availability of modern diagnostics and therapeutics and the transfer of capabilities to the patient to effectively manage their own risk benefit decisions.  Absent these the relationship exists inside a medical demilitarized zone absent modern weapons to fight disease or the tools to make wise decisions.  For the relationship-based care movement to be meaningful in terms of positive impact on the relationship, patients and physicians must not only have access to each other but also access to the full range of modern science and technology within the context of expanded consumer risk management.

Studies have shown that America’s physicians and patients have taken such access for granted (Magee, 1998).  Both groups see science and technology as the primary determinant of success of American medicine over the past two decades.  Patients largely agree that health care today is more beneficial and less risky than it was ten years ago. Although they identify their relationship as compassion, understanding,  and partnership, they identify the healthcare product as all of the above, plus quick and effective diagnosis, and counseling on how to make wise decisions and accomplish payment.  Thus, phase three of the evolution of the patient-physician relationship, engagement, requires access that is informed, responsible, and complete.  These expectations require investment of both time and money further challenging a market place with high levels of uninsured and an insurance industry facing employer pressures, limited ability to perform accurate and timely cost/benefit analysis, and continued reliance on short term component management rather than long term disease management.

From the engaged health consumer’s vantage point access implies both choice and responsibility.  With regard to choice, recent studies indicate that 90% of Americans believe a multi option plan to be of great importance when faced with a disease.  81% believe more than one choice of medicine is very important and 82% prefer several options with varying degrees of risk when faced with a medical challenge.  91% believe they are currently managing their own health but their willingness to self manage is somewhat ahead of the sophisticated capability to manage reasonable risk.  For example, while 93% are willing to accept risk in a prescription medicine that cures a disease, only 49% are willing to accept risk to prevent a disease.  In addition, the willingness to follow a physician’s advice is tied to the patient’s perception of the seriousness of the disease or condition.  Both these realities lock consumers into a reactive stance and allow disease to control them rather then having them control disease.

Moving the patient-physician relationship to phase three, engagement, necessitates enlightened health policy to assure coverage, access and choice, and requires the transfer of consumer risk management from doctor to patient.  An examination of “best practices” from other industries would be beneficial.  For example, when 401K’s became commonplace for American employees, the financial industry developed graphic tools such as the risk pyramid to assist consumers.  Other tactics that have promise include providing patients with prompting questions to ask their doctor by disease; educational programs that link patients, doctors, pharmacists and families; reinforcement of short term risk for long term benefit (prevention) and accurate portrayal of the seriousness of diseases.  Emphasizing dual responsibility is equally important.

In 1997, the AMA declared that “The creation of the physician-patient relationship is contractual in nature”.  Recently, there has been heavy emphasis on physician responsibilities and patient rights. However, in light of the movement toward mutual partnerships and shared risks, it is essential that we recognize that although patients have rights, they also have responsibilities in a fully consummated relationship.  In 1998 a group of medical and health consumer experts on the patient—physician relationship were convened in Boston, Massachusetts, and asked to identify the responsibilities of patients, physicians, and health policy experts in light of their rapidly evolving relationship. Their conclusions:

For the patient:

1. Be truthful.  Do not hide facts or exaggerate symptoms.  The relationship is based on the free flow of confidentially held sensitive information.  Inaccuracy threatens your health and the relationship.  Respect the confidentiality of your communications with your doctor.
2. Give the relationship time.  As with all complex human encounters, this relationship needs time to mature and develop.  Get to know each other.  Be open to a partnership in decision making.
3. Take responsibility for learning.  Your body is complex.  Commit to understanding how it functions and keep it healthy.
4. Take responsibility for your health.  Know thyself means more than just knowing what diseases you have and what medications you are taking.  It also means having a well-defined health philosophy for you and your family.  They are partners in this relationship as well.
5. Raise issues of concern.  Hidden issues, left unsurfaced, will ultimately compromise even a stellar relationship.  If something is bothering you-the doctor is rushing, the staff is rude, the room is cold, whatever-speak up.

For the physician:

1. Act with the highest professional competency.  Trust requires a high level of physician competency and the ability to culturally connect and communicate clearly one-on-one.
2. Master the skills of communication.  Part of creating a good match is the ability to communicate complex science in layman’s terms and in a neighborly way.  Help patients understand and absorb medical developments.  Always honor confidentiality.
3. Allow patients to share ideas and help formulate priorities.  In an environment where time is a limited commodity, priority setting needs to be collaborative and ideas that are urgent to the patient must be permitted to surface.
4. Acknowledge the fullness of your patient.  Wellness and illness are highly individualistic.  They must be interpreted within the context of family, job, finances, and mental and spiritual health.
5. Respect your fellow professionals. Patients expect their doctors to work well with each other and with other caregivers.  Turf battles are a nightmare for the patient.  Open disagreement and rude interprofessional behavior cause patients to question their physician’s credibility and capability.

For policy experts:

1. Relieve some of the physician’s pressures for time.  Of physicians, 41% have reduced  the time spent with each patient in the past 3 years.
2. Encourage the physician’s role as patient advocate.  Although the physician may continue to have to act as a double agent, providing care while conserving resources, he or she should never have to act as a secret agent.
3. Encourage integrated comprehensive care.  Aligning the continuum of care is essential.  Physician leadership must extend beyond clinical continuums to educational continuums.  Enlightened managed care must abandon component management once and for all and embrace disease management and the transformational potential of new discoveries and new approaches.
4. Expand access. If real estate is location, location, location, relationship-based care is access, access, access.  This includes defining unique strategies to bring patients into the system, reinforcing face-to-face interaction and ensuring that when patients and physicians encounter each other, they have unimpeded access to modern diagnostics and therapeutics.
5. Individualize care.  The movement towards measurable quality, critical pathways, and cost-efficient decision making has begun to address unacceptable variability in clinical decision making and cost.  That said, some level of practice variation must be preserved if physicians are to continue to engage patients as individuals with unique features.  Overcategorizing patients runs the risk of disengaging the physician from the patient-physician relationship.
6. Support process improvements that expand respect for patients.  Compassion, understanding, and partnership are often expressed by little gestures that denote respect for patients.  Temperature, touch, eye contact, timeliness, tone and dress all have meaning to patients.  At the very least, students should be taught to be sensitive to these messages.

Relationship based healthcare requires compassion, understanding and partnership. It is not passive but decidedly active. All have roles. All have responsibilities.  It is fundamentally participatory, planning based and outcomes focused.