Modules

A brief history of physician-patient communication

Physician-centred approach pre-World War II

The following is a short listing of some major trends. There have been and continue to be physicians who practice a variety of models of communication.

Pre-World War II

  • Physicians were highly regarded, paternalistic and patients trusted them to behave in their best interests.
  • Physicians were disease oriented (physician-centred).
  • There were few effective treatments to offer patients.
  • Most physicians were generalists and knew their patients well.
  • Interview: Physician-centred approach

  • Physician: There is no doubt. Your symptoms are due to gallstones, Cynthia. Now we’ll get an ultrasound and I’ll arrange a consult with one of our surgeons, okay?

    Patient: Surgery? But are you sure doctor? I thought it was just indigestion. You see we’re planning this family trip and I’d hate to ruin it for them.

    Physician: Yes, Cynthia, I am quite sure now. This is your health we’re talking about. And you can take a holiday anytime. So we’ll just arrange that, okay?

     

Physician-centred approach post-World War II (~ 1950-1975)

  • Interview: Physician-centred approach

  • Physician: I’m sure your symptoms are due to gallstone, Cynthia. Now, there are several ways in which to handle this. First of all, you can do nothing and you may not have another attack. Secondly, you can try dieting, cut down the fat in your diet to see how that works for you, and otherwise, well you can try surgery.

    Cynthia: Oh…

    Physician: Now there are two ways. There’s laparoscopic surgery and if you have trouble with that, they may just have to open you up.

    Cynthia: Yes but…

    Physician: But it’s your choice which surgery you’d like to try. Have you thought about a surgeon, you have any in mind?

    Cynthia: No.

    Physician: Well, there’s a few that I can recommend or you can try the internet. Good.

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.

  • Interview: Patient-centred approach

  • Physician: Well from what you’ve told me, Cynthia I think the problem might be gallstones now. Did you have any worries or concerns about what it might be?

    Cynthia: Well not really worries, I mean I hoped it was just indigestion but gallstones, doesn’t that mean surgery?

    Physician: It could be, yeah. It’s likely.

    Cynthia: You see we’re planning this big family trip soon and I’d hate to ruin it for them. Is there anything I could do like a diet?

    Physician: Sure, you can cut down on your fat intake since fat can provoke the attacks. At some point, they may have to be removed though and we don’t want it to go over too long before it becomes serious but listen, it’s not an emergency now. Maybe we can work around that family vacation. So tell me, where do you plan on going and for how long?

    Cynthia: We’ll be going for two weeks we’re heading down to Mexico with the whole family on a resort on the Pacific coast.

    Physician: Wonderful, good.


 

Next: The patient-centred model of physician-patient communication

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