Physicians became even more overtly disease oriented as:
- More effective therapy became available (e.g., antibiotics).
- There was an explosion of diagnostic and therapeutic technology.
- Specialization and research increased, which tended to distance the physician from their patient.
The physician-patient relationship was still strongly paternalistic, not because the physician knew the patient well enough to know what was best, but because the physician now had a much larger store of effective knowledge and treatments, resulting in:
- An even greater separation of the physician and patient, in terms of communication.
- Increasing dissatisfaction with visits to physicians.
- Patients felt they were neither heard nor understood.
- Increasing distrust of physicians, who were thought to be more interested in money, and fame in the case of researchers and specialists.
- In some societies, a contractual, consumer model of the physician-patient relationship emerged. Physicians would show their wares and patients, with access to more knowledge, could shop around.
Medical training reflected the advances in biomedical knowledge, focusing on disease and the increasingly complex technology of medical practice. The dissatisfaction of patients was largely ignored as being irrelevant to patient care. Most physicians who are now practicing were trained in this biomedical focused, physician-centred system. History-taking was the type of patient communication that was taught. In other words, physicians were taught to have a dialogue that was focused on asking questions to find out what kind of disease or abnormality was sitting in the office.
By the mid-1980s, the call for change in physicians’ behaviours was insistent, driven in part by the right’s movement, the consumer movement and the appearance of the field of bioethics, which emphasized patient autonomy as a goal of care. In the last 15-20 years, many medical schools recognized the need to revise their curriculum to include communication skills. They began to look to those whose approach to the physician-patient relationship recognized the importance of the patient’s role in the dialogue. Among them were:
- Balint, who started discussion groups to talk about “difficult” patients
- Engel, whose biopsychosocial model was one of the first models of holistic medicine
- Cassell, who described the difference between disease and illness and language as a critical tool of medicine
- Kleinman, who expanded patient-centred attitudes to all cultures
- Stewart, Levenstein and McWhinney, developers of the Patient-Centred Clinical Method
Full references to these authors can be found in the Bibliography.