For centuries, healers had little understanding of disease and lacked the technologies we now know are necessary for the treatment and cure of many diseases. Physicians had few medications, and surgery was only a last resort. In fact, the most important tool for healing was the relationship between the physician and the patient. Interpersonal relationships have a powerful influence on both morbidity and mortality (House et al., 1988). Social connectedness enhances health in both direct and indirect ways: directly regulating many biological functions, decreasing anxiety, providing opportunities for new information, and fostering alternative behaviors (Hofer, 1984). We know little about the basic mechanisms by which interpersonal relationships, and the physician–patient relationship in particular, operate (Ursano and Fullerton 1991). However, clinical wisdom holds that both the reality-based elements of the physician–patient relationship – in modern times referred to as the working alliance or the therapeutic alliance (Zetzel, 1956; Greenson, 1965) – and the fantasy-based elements of that relationship affect the patient’s pain, suffering and recovery from illness.
Physicians learned through trial and error to interact with their patients in ways that relieved pain and promoted health (Frank, 1971). Often the physician’s only interventions were reassuring patients, providing knowledge about the patient’s disease, accept-ing the patient’s feelings of distress as normal, and maximizing the patient’s hope for the future. Although these interventions, based on wisdom and intuition, are no longer the only tools available to the physician, they continue to be an important part of the physician’s and particularly the psychiatrist’s therapeutic armamentarium.
Such nonspecific aspects of cure are often thought to be mystical or mysterious. In fact, in biological studies they are rec-ognized as the placebo effect. Oddly, these effects of interper-sonal relationships are both one of the prized and one of the most denigrated aspects of all of medicine. Yet, as clinicians, we all strive to alleviate our patients’ pain and suffering and return them to health as soon as possible with whatever tools may help. Many well-designed studies show that 20 to 30% of subjects respond to the placebo condition. Recent studies show that analgesic pla-cebo has similar neural mechanisms to opioid analgesia (Petrovic et al., 2002). The problem with placebos is not whether they work but that we do not understand how they work and, therefore, we do not have control over their effects. As a physician, one strives to maximize one’s interpersonal healing effects and, in this way as well as with other healing tools, increase the chances of our patients’ relief from pain and of recovery.
The physician–patient relationship includes specific roles and motivations. These form the core ingredients of the healingprocess. In its most generic form the physician–patient relation-ship is defined by the coming together of an expert and a help seeker to identify, understand and solve the problems of the help seeker. The help seeker (in modern terms, the patient) is moti-vated by the desire and hope for assistance and relief from pain (Sullivan, 1954). A physician is required to have a genuine interest in people and a desire to help (Lidz, 1983). Simply stated, “the se-cret of the care of the patient is in caring for the patient” (Peabody, 1927). Caring about and paying attention to a patient’s suffering can yield remarkable therapeutic dividends. More than one attend-ing physician has been reminded of this when a patient deferred making a treatment decision until he or she was able to consult with “my doctor”, who turned out to be the medical student.
In today’s technology-driven medicine, the importance and complexity of the physician–patient interaction are often over-looked. The amount of information the medical student or resident must learn frequently takes precedence over learning the fine points of helping the patient relax sufficiently to provide a thorough his-tory or to allow the physician to palpate a painful abdomen. Talk-ing with patients and understanding the intricacies of the physi-cian–patient relationship may be given little formal attention in the medical school curriculum. Even so, medical students, residents and staff physicians recognize, often with awe, the skill of the sen-ior physician who uncovers the lost piece of history, motivates the patient who had given up hope, or is able to talk to the distressed family without increasing their sense of hopelessness or fear.
The relationship between the physician and the patient is es-sential to the healing of many patients, perhaps particularly so for many psychiatric patients. The physician who can skillfully recog-nize the patient’s half-hidden comment that he or she has not been taking the prescribed medication, perhaps hidden because of feel-ings of shame, anger, or denial, is better able to ensure long-term compliance with medication as well as to motivate the patient to stay in treatment. Regardless of the type of treatment – medication, biofeedback, hospitalization, psychotherapy, or the rearrangement of the demands and responsibilities in the patient’s life – the rela-tionship with the physician is critical to therapeutic outcome.
Modern medicine emphasizes a specific role for the physi-cian in the relationship with the patient. In many Western coun-tries, the patient comes for help with a specific problem, the doctor’s office staff secures permission from a third party payer for the doctor to conduct a particular treatment, a prescribed intervention, which will take a specified amount of time. Dec-ades ago, when the doctor was neighbor, advisor and friend to the patient and routinely invited to important family events inthe patient’s life such as weddings of children, and when doctors routinely cared for more than one generation of the same family, the physician typically assumed that he or she would be a source of strength and assistance to the patient throughout the cycle of life. This meant more than curing a specific disease or relieving a specific pain.
While today’s patients may not consciously expect that the physician’s influence and healing powers will take many forms in a complex interpersonal relationship, human nature is still the same, and patients still want from their doctors many nonspe-cific forms of emotional support which can promote a sense of well-being and better health. Though modern doctors may feel a great deal of time pressure to see many patients each day and to focus narrowly their healing efforts, the physician must also be sensitive to the many needs of patients, who believe that the physician is possessed of wisdom and understanding. Sensitivity to such desires and needs will promote effective medical care in all specialties, with all patients. A view that such patients are unusually needy and demanding will not serve the cause of ef-fective medical care.
Finally, in today’s mobile and geographically evermore united world, the importance of recognizing the needs of patients from parts of the world other than that of the physician’s is a chal-lenge to the practitioner. The physician must be open to the limita-tions of his or her knowledge of the expectations, beliefs and likely behavior of patients from different cultures, nations, religions, and ethnic and socioeconomic backgrounds. The physician must rec-ognize this challenge and one hopes, embrace it with enthusiasm. It can make the practice of medicine a more exciting experience.
The physician–patient relationship is also a source of information for the physician. The way the patient relates to the physician can help the physician understand the problems the patient is experiencing in her or his interpersonal relation-ships. The nature of the physician–patient relationship can also provide information about relationships in the patient’s child-hood family, in which interpersonal patterns are first learned. With this information, the physician can better understand the patient’s experience, promote cooperation between the patient and those who care for her or him, and teach the patient new behavioral strategies in an empathic manner, understanding the patient’s subjective perspective, that is, feelings, thoughts and behaviors.
These clinical vignettes illustrate that the physician–patient relationship is composed of both the reality-based component (the working alliance or therapeutic alliance) and the fantasy-based component (the transference) derived from the patient’s patterns of interpersonal behavior learned in childhood. Either or both of these may maximize or limit the patient’s sense of reassurance, available information, feelings of comfort and sense of hope (Meissner, 1996). In this way, the nonspecific curative as-pects of the physician–patient relationship may be enhanced or diminished.