Physician-patient, a relationship in crisis

The physician-patient relationship has been going through a profound crisis for years, with consequences not only for individual health but also for public health. We met with Prof. Fabrizio Asioli to talk about the issue.

Interview with Prof. Fabrizio Asioli, psychiatrist, author of the italian-language book La Relazione di Cura (The Caring Relationship)

The physician-patient relationship has been going through a profound crisis for years, with consequences not only for individual health but also for public health. We met with Prof. Fabrizio Asioli to talk about the issue.

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Social networks and the COVID-19 pandemic are the latest elements, in chronological order, that have contributed to exacerbating this crisis.  The anti-vax movement and the spread of so-called alternative medicine are the natural consequences of a suffering physician-patient relationship, which is no longer based on such cornerstones as trust in the physician, and knowledge on the side of the patient. To explore this issue, we met with Prof. Fabrizio Asioli, a psychiatrist and psychotherapist, author of the italian book “La relazione di cura - Difficoltà e crisi del rapporto medico-paziente” (The Caring Relationship - Difficulty and crisis in the physician-patient relationship).

In your book you describe the crisis in the physician-patient relationship. In short, how serious is this crisis?

There are many causes leading to this crisis. Some are subjective, such as individual physicians who are not very patient and do not devote enough time to their patients. Others are objective, structural. In my book I try to support the thesis that the current crisis in the physician-patient relationship arises from a structural change which, paradoxically, is linked to a positive fact in the history of medicine. I am referring to the great development that medicine has had in the last fifty years. This tremendous development has had repercussions that have greatly complicated the physician-patient relationship.

Firstly, specialisations and ultra-specialisations have emerged, leading to a fragmentation of the patient and their body. Today it is difficult to imagine that a physician knows everything, everyone knows they area of focus, and it is understandable that this should be the case. The hepatologist is interested in the liver, the cardiologist in the heart, and so on. The patient perceives this fragmentation and often there is no physician who has the relationship with the patient in hand. The general practitioner, who should be the figure in charge of this responsibility, is often underestimated. The patient has the perception that the importance of the person has been lost sight of, i.e. that the interest of medicine today is more oriented towards the individual organs than towards the person.

The second major positive change is that the diagnostic tools available to medicine today are extraordinary, allowing us to see inside the patient's body in detail. They have replaced the manual skills of symptomatology (also known as semiology), palpation and auscultation. But with them also disappeared the reassuring power of the hands to touch people. Edward Shorter, a medical historian, argues about the paradox that patients started to feel less cared for when medicine started to care for them better.

Better treatments, greater availability of drugs, and more therapeutic strategies aimed at diseases has been matched by a distancing of physicians from "the human" that comes before "the patient". Naturally the patient suffers from this reduction in the presence of the physician, and this translates into a loss of confidence in the physician and in medicine.

Do you think there is any action on the horizon, even if in the not-so-near future, to counter and overcome this crisis?

From this point of view I am quite pessimistic, because in general there is little awareness about this crisis. Years ago I conducted a survey among colleagues in Emilia Romagna (Italy) and the results clearly showed the lack of awareness of the problem among physicians, some of whom even denied a crisis in the relationship between physicians and patients. Today, probably nobody denies the crisis anymore. However, many physicians downplay it, identifying causes that are actually effects of a process that they do not understand.

True, today there is little time for too many patients. True, today patients are more demanding, too demanding, sometimes rude. True, the spread of the Internet has changed the role of the physician, who is often a second level consultant, with the patient arriving at the surgery already having an idea of what they have and how they should be treated. This is all true, but without an awareness of the problem in its entirety, of the cultural, social and scientific changes underlying it, there is no way of finding solutions.

What impact is the COVID-19 pandemic having on this care relationship?

The pandemic is certainly affecting the relationship between physician and patient, in a contradictory way. There are positive consequences, no doubt. For example, seeing physicians in hospitals taking care of critical patients in intensive care has improved the social image of medicine. Physicians, as well as all health professionals, were highly appreciated for this. Other consequences were less positive. One example is the anti-vax phenomenon, which is the most explicit expression of the total lack of trust in medicine and healthcare professionals.

Do you think that the impact of the pandemic is different among family physicians than among hospital physicians?

The impact has been felt by all physicians, but in my opinion, as far as the physician-patient relationship is concerned, this impact has been more significant for family physicians, i.e. general practitioners and paediatricians. I believe that the general practitioner (and the paediatrician, for the younger ones) should be the central pivot of any quality health system. This is already the case in Anglo-Saxon countries, for example, where family physicians are at the base of the system. In Italy today this is not the case, this figure is no longer so central. In my opinion, this important role arises precisely from the possibility of building a privileged relationship with the patient, which can have considerable (and today measurable) effects on the treatment process.

The general practitioner and paediatrician have a structural advantage over specialists: they know the patients, they follow them not only for one episode of illness, but follow them through their life development, and this generally makes them worthy of the patients' trust. The specialist, who often sees the patient a couple of times at most, is worthy of the patient's esteem, but there is no basis for a relationship of trust. That is why the pandemic, having prevented meetings, visits, or the daily routine of the surgery, has had a greater effect on the physician-patient relationship for specialists than for general practitioners.

The pandemic has accelerated the development of telemedicine in several countries. How does telemedicine - not only the ability to make remote visits via an electronic device, but also, for example, to monitor clinical conditions remotely via patient-worn devices - fit into the relationship between physicians and patients?

Telemedicine is an excellent technological opportunity to monitor symptoms, to collect data, to intervene even with pharmacological corrections. However, if these operations do not lead to a synthesis in the relationship of a physician with a specific patient, then I fear that this technology will risk alienating physicians and patients even more. We will have more and more powerful and effective technologies, but if it replaces the relationship with a caregiver, with someone who takes care of that person, I think the distances will increase. I think it is very difficult to talk about therapy outside the relationship between physician and patient. You can talk about pharmacological treatment, but not about therapy.

During this pandemic, we have witnessed the proliferation on social networks of mutual aid groups asking for information, but also for diagnoses and treatments, exchanging lists of drugs of unspecified effectiveness. It seems that in some of these groups there are physicians who give advice and prescribe drugs via chat. In light of your experience and studies, do you think that a physcian can treat someone they do not know? Also, how can a patient trust someone they do not know?

I think that self-help groups have a great beneficial potential, also the online ones. I think it is good that patients with a certain pathology can engage with each other and share their personal experiences. They represent a network of solidarity to hold on to, in particular during difficult situations. But self-help groups should not become self-care groups. I am not aware of anything useful here.

Administering therapy is a noble art, and a very complicated one; it cannot be trivialised with a list of drugs for everyone. Administering therapy is also administering and taking drugs, but not only that. It is about administering words and closeness. Caring for a patient involves two acts, which are not always sufficiently clear, even for us physicians. The first act is that of treating, but before treating, it is necessary to reassure the patient in crisis, because they may have a serious illness. Before examinations, before drugs, first of all a patient needs not to feel alone, but to know that they have someone close to them in whom can have complete trust and who will help them to overcome this situation. Care has this double meaning, which is preserved in any kind of trouble occuring within a relationship between those who need care and those who are willing to give it. Outside this context, that of the therapeutic relationship, there can be no therapy. One cannot treat someone one does not know, one cannot be treated by someone one does not know. An anamnesis via chat and a list of medications are not enough.

The physician-patient relationship has been central, and itself therapeutic, over the last 4,000 years of history, in all cultures, in all countries, in all forms of medicine. The proximity of a competent person, who can hopefully help us when we need help medically, is a central value of therapy, even today.

How does the continuous presence of physicians on television, in newspapers and on social media affect the relationship between physician and patient?

The answer to this question cannot be unequivocal. Simplify things a lot, we can say that there are two categories of colleagues, who have appeared, appear and reappear on television, who are present in newspapers and on social networks. There is a category of colleagues whose main purpose is to inform. Giving information to the public is not wrong, but it would be important to learn how to communicate certain information to a large and heterogeneous public. A competent physician who is able to communicate strengthens the social image of medicine.

Others, however, have different objectives and seem to go on television to excel, to argue, to appear. They contribute to giving an image of a divided medicine, torn apart internally. It is obvious that this is bad for the physician-patient relationship, because it contributes to distancing medicine, physicians and patients.

Who bears the greatest responsibility for the current crisis of confidence in physicians?

In some way, all physicians are responsible for a certain number of people turning away from medicine. Subjectively, in one's own practice or in one's own department, through one's own individual actions, everyone bears a share of the responsibility. From the collective point of view, the real responsibility lies in not having been able to grasp the incredible development of medicine in the last decades, in not having been able to become aware in some way that medicine was changing and moving away from patients. Not having had this awareness has so far prevented us from limiting the damage. There are subjective responsibilities, but the problem is bigger and needs to be addressed.

In your book "The caring relationship" you talk about the need to train physicians specifically in the therapeutic relationship, in the relational needs of the patient, in how to satisfy them. Assuming that this specific training is implemented, would it be sufficient to overcome the crisis in the physician-patient relationship?

No, I don't think it is enough, but it could certainly help to take a first step. We could start by teaching skills to pay more attention to the patient as well as to the disease. Let's take oncology as an example, a discipline that is making tremendous progress and that over the years has changed from a speciality that almost always gave a diagnosis with a negative prognosis to a speciality that manages to cure many patients. Oncology has had an extraordinary capacity for development in terms of therapeutic and preventive intervention, but there is no medical school in which, in addition to the focus on drugs and early diagnosis, there is the same attention to the patient, to their psychological reactions to the diagnosis of cancer, to the actions to be taken to support their distress.

It could also be taught to have a broad view of therapy, which is not just made up of pills, but depends very much on the relational capacity of the physician, on being close to and reassuring the patient. What Balint wrote in his book "The Doctor, His Patient and The Illness" (1961) is still valid: The discussion soon revealed that by far the most used medicine in general practice is the doctor himself, namely that it is not only the bottle of medicine or the box of pills that count, but also the way the doctor offers his patient, indeed the whole atmosphere in which the medicine is given and taken1.

Physicians need to learn how to administer themselves as a "medicine" because they generally do not know how to do this. They therefore fail to use this powerful therapeutic factor, given by their relational capacity, when they do.

Is there a relationship between the physician's ability to relate to the patient and the risk of burnout?

I believe that if the physician acquires this ability to administer themselves as a medicine, they are able to receive greater gratification from the potential professional fatigue. So, of course, it would limit the risks of burnout, which is not only caused by physical fatigue, but also, on a psychological level, by dissatisfaction with the amount of work done. This ability of the physician to recover the part of taking care of the person could be an element that limits the risk of burnout.

1. Editor's note: this is not a direct quote from the book.