The Patient Will See You Now – The Evolution of the Doctor-Patient Relationship

Beneficent paternalism: the early years of the relationship

Since the days of ancient Egypt, man has attempted to master fears of helplessness, sickness and death through magic, mysticism and even theology. Healers were as much magicians and priests as they were doctors, and magic was an integral part of care. The notion that the doctor-patient relationship evolved from the priest supplicant relationship was proposed by Edelstein et al in 1937.¹¹

For most of the past 3,000 years, the basic style of doctoring can be described as ‘beneficent paternalism’. The medical profession has adopted a well-meaning parental role in most patient encounters. Doctors have acted on behalf of, and for the good of, their patients. They have also wielded power over them. This role, which until recently has been taken for granted by society, produces behaviour that is disease-oriented with a strong tendency towards authoritarianism.²

In this paternalistic model of the doctor-patient relationship, the doctor uses their skills to choose the necessary interventions and treatments to restore the patient’s health or ameliorate their pain. Informing patients about the uncertainties and limitations of medical interventions is thought to undermine the faith so essential to therapeutic success. Any information given to the patient is selected to encourage them to consent to the doctor’s decisions.²

This paternalistic attitude is thought to be promoted by the dependency and submissiveness shown by many patients. It may lead to doctors overlooking the patient’s wishes and concerns, as they pursue their own professional agenda.¹³

New millennium, new relationship

Paternalism is an imbalanced interaction between doctor and patient and has been challenged during the last few decades.¹⁴ Over this period, an extensive body of literature has emerged that advocates a more patient-centred approach to medical care.¹¹ It promotes a shift in the doctor-patient relationship from the ‘guidance-cooperation’ model to ‘mutual participation’, whereby power and responsibility are shared with the patient.¹⁵

Angela Coulter's 2002 book 'The Autonomous Patient’ ventured that paternalism has had its day. She talked about redefining the patient’s role to emphasise autonomy, emancipation and self-reliance rather than passivity and dependence.¹⁶ 

“No longer is he or she simply a victim of illness. In the 21st century patients must be treated as co-producers of their own health and care-managers when they are ill. They must be encouraged to see themselves as decision-makers, evaluators and stakeholders with a key role in shaping health policy.”¹⁶

This new alliance between the doctor and patient, based on cooperation rather than confrontation, requires the doctor to understand the patient as a unique human being, according to Enid Balint’s prescient 1969 article. Balint argued that the patient, not the illness, should be the primary focus of medicine such that the primary objective of the doctor is to listen to the patient in order to identify what the ‘real’ problem actually is, instead of simply eliciting signs and symptoms.¹⁷

In the 1990s, both Stewart et al.¹⁸ and Grol et al.¹⁹ also asserted that the patient-centred approach requires a willingness to become involved in the full range of difficulties patients bring to their doctors, not just their biomedical problems. 

Professor Teresa Hellín goes as far as to suggest that patient-centricity is a fundamental requirement for being a physician: ‘‘…one of the essential qualities of the clinicians is interest in humanity, for the secret of the care of patients is in caring for the patient’’.¹

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