Originally published October 2012
Trust, loyalty, and honesty are the foundations of a good doctor-patient relationship and of professionalism in the practice of medicine. Applying these values in everyday practice can be, at times, a challenge for physicians.
How do physicians demonstrate to patients and their families the high standard of professionalism that is expected of them, particularly when faced with difficult and often highly stressful situations?
Trust and loyalty
The requirements of the Canadian Medical Association's Code of Ethics and the Collége des Médecins du Québec Code of Ethics of Physicians define the general responsibilities of physicians. In addition to the provision of clinical care, this may include initiating and dissolving a doctor-patient relationship, effectively communicating treatment and care options, and protecting privacy and confidentiality.
The special relationship of trust between physicians and their patients, known as a fiduciary relationship, requires that physicians always act in their patients' best interests. In order to uphold the required standards of professionalism, physicians must maintain appropriate boundaries — a professional distance — with patients. Professional conduct for physicians includes maintaining appropriate relationships with patients, as well as setting limits on the nature of relationships with patients, on accepting gifts, and on treating one's family members and friends.
Given the unique situations in which physicians can find themselves, determining appropriate boundaries may not always be straightforward. When in doubt, physicians can obtain guidance from medical regulatory authorities (Colleges) or the CMPA.
Courts have long recognized that the doctor-patient relationship is built on trust; this relationship of trust is recognized as fiduciary duty. Physicians must act in good faith and demonstrate loyalty toward the patient, never placing their personal interest ahead of the patient's.
Physicians should take care to be honest in their communications with patients and families. However, there are many situations in which these communications will necessarily be difficult, both for the physician and the patient (and family). The skills that enable effective communications in positive circumstances are not necessarily sufficient to fulfill the full range of requirements during more difficult clinical scenarios.
Accordingly, physicians should develop skills in interviewing patients, breaking bad news, or denying a request for an unnecessary diagnostic test.
Physicians must also be honest with patients when it comes to clinical research. In fact, the ethical principles governing clinical care and research can be fundamentally distinct. If doctors clearly tell patients that the goal of clinical research is not primarily to optimize their clinical care but to advance knowledge for the benefit of future patients, then both patients and doctors will have a more transparent view of research. In this way, patients may be viewed as partners in the process of advancing medical knowledge.1
Honesty and compassion are also essential when disclosing harm from healthcare delivery to patients. Despite a physician's best efforts, poor clinical outcomes, including adverse events (accidents in Québec), can happen. Disclosure is the process by which an adverse event is communicated to the patient. Physicians and other healthcare providers have ethical, professional, and legal obligations to disclose adverse events. Disclosure is more likely to be effective when the physician possesses the necessary communication skills related to content, manner, and listening.
- Content refers to the words, tone, and presentation of facts.
- Manner refers to the physician's appearance and demeanour, and attentiveness to the patient's needs.
- Effective listening includes sensitivity to language barriers, checking that the patient appears to have a good understanding of the situation, and responding to questions.
Physicians should disclose adverse events to patients as soon as it is reasonable to do so, and details from the disclosure discussion should be documented in the medical record. Following harm from healthcare delivery, patients have clinical, emotional, and information needs. The initial disclosure should focus on the clinical situation and mitigating harm. Discussions should be limited to the facts and should avoid speculation. After an appropriate analysis, additional facts related to the reasons for the harm should be discussed with the patient. Physicians are encouraged to provide an appropriate apology at every disclosure meeting. Patients and families will wish to learn of safety improvements to prevent similar events, if possible.
The CMPA has published extensively on effective disclosure (see Communicating with your patient about harm: Disclosure of adverse events) and members are encouraged to contact the Association for advice.
Physicians demonstrate their professionalism when they show respect for their patients and families. Lengthy waits at the doctor's office, rushed appointments, and interruptions can all be interpreted by patients as signs of disrespect. While unexpected situations and complex patients can be difficult to plan for, physicians should follow good practices in appointment scheduling. Physicians should also recognize that, while they may see many patients in the course of a single day, each of these patients is individually assessing the manner in which they have been treated, both clinically and professionally.
One way a growing number of physicians manage their appointment schedules is by implementing a one-problem-per-visit policy. Some patients may see this practice as disrespectful, which may further expose doctors to medico-legal difficulties. Although physicians are trained to listen carefully to a patient's health concerns, the risk of not detecting serious health problems may increase if patients feel constrained when speaking with their physician. Patients should be allowed sufficient time to describe fully the reasons for the visit. Following this, doctors should prioritize the problem list and arrange appropriate follow-up visits, as required.
Responding to third party requests is another important way physicians demonstrate respect. Completing medical reports for insurers, lawyers, or other third parties on behalf of patients is important, and is a sign of professionalism. If the patient has authorized the release of the information, and the physician has information required for the report, then a timely, clear, and factual report should be provided. If circumstances preclude a prompt response, physicians should send a reply acknowledging receipt of the request and an indication as to when a full report can be expected. Physicians should indicate in advance the fees that will be applicable to complete such a report.
Most physicians experience difficult doctor-patient relationships at some point in their practices and may occasionally feel it necessary to end such a relationship. In these circumstances, physicians are ethically permitted to end a doctor-patient relationship provided the patient does not need urgent or emergent care, and the patient is given adequate notice to find another physician. In Québec, a physician is also required to have reasonable and just cause to end the relationship. Human rights legislation, College policies, and codes of ethics that prohibit discrimination in the provision of medical services may also affect a physician's ability to terminate a doctor-patient relationship.
Conflict in a doctor-patient relationship can stem from many sources including, but not limited to, inappropriate or threatening patient behaviour, unfounded expectations of clinical outcomes, or a patient's provision of deliberately misleading information. Physician factors, for example poor communication or a chronically late medical office, can also lead to conflict with patients. As a professional, it is the physician's responsibility to manage the conflict in a way that demonstrates compassion and respect — and that does not open the physician to potential medico-legal difficulties. In most cases, physicians will want to resolve challenging patient relationships by understanding the reasons behind a patient's behaviour.
In keeping with good practice, physicians are reminded to examine their communication style, attitudes, conduct, office practices, and other factors that might negatively impact their rapport with patients. Physicians may find it beneficial to enlist help from colleagues. Behaving professionally with patients and families can also help to minimize conflict and contribute to quality care.
If desired by both parties, a damaged doctor-patient relationship can be successfully restored, even after a patient has complained to a hospital or College. Communicating openly and honestly, clarifying mutual expectations, and setting ground rules for moving forward can contribute toward rebuilding a trusting and effective connection between doctor and patient. Seeking feedback from patients and families may also help to strengthen the doctor-patient relationship.
Several factors are changing the dynamics that have characterized the physician-patient relationship; many of these deal with the changing expectations of patients. The fiduciary relationship between a physician and his or her patient has long been founded, in part, on the imbalance in relevant knowledge between the 2 parties. However, through their access to a wide range of sources, patients now have more information about medical conditions, diagnoses, and procedures. Some patients are now better informed about their clinical conditions and care options, while others possess incomplete or inaccurate information.
The proliferation of information may also be contributing to unrealistic expectations about clinical outcomes. While a fictional television depiction of a certain procedure or media reporting of improved clinical results do not make such outcomes applicable in every case, they do serve to raise patient expectations. These potentially unrealistic expectations have implications for the physician-patient relationship and, should the outcomes not be achieved, could create possible medico-legal exposures.
Expanding channels of communication also introduce new possibilities and risks for physicians. Electronic health records, email, web portals, smartphones, and tablets are just some of the tools that result in both challenges and opportunities for doctors. As these technologies evolve, physicians will be faced with new prospects to help deliver superior and safe patient care. Professionalism requires physicians to ensure that any patient or situation cannot be identified by the sum of information available online.2 Medical professionalism in the virtual world will be strengthened by physicians' commitment to confidentiality and privacy.
The influence of social media will also introduce new complexities in the physician-patient relationship. Social networking services such as Facebook are expected to grow and physicians will have to assess the potential benefits and risks of these social utilities. While social media undoubtedly enhances connections among people, physicians must be cautious in their use of this technology and should be guided by their continued commitment to confidentiality and privacy. Physicians should assess the potential benefits and know the risks associated with social media and other new technologies. Doctors may be surprised by how easily accessible and durable their online information is.3 Many Colleges have guidelines on the use of social media. CMPA members can also read the article, "Technology unleashed — The evolution of online communication" recently published by the Association.
The CMPA case files indicate that 89% of closed cases related to professionalism are College cases, and the majority of these result in an unfavourable outcome for the physician. Some of the physician behaviours identified in these cases include unprofessional comments, lack of sensitivity, a dismissive or demeaning tone, and angry outbursts. CMPA members are encouraged to reflect on their communication style and behaviours with patients.
Professionalism with patients and families involves both concrete actions such as developing knowledge and skills in the doctor-patient relationship, and demonstrating important characteristics such as trustworthiness, honesty, and respect. Physicians should disclose adverse events to patients, and should consider apologizing when appropriate. In this respect, doctors are encouraged to reflect on professionalism from the point of view of patients and families.
Physicians are also encouraged to recognize that patient expectations, be it of clinical outcomes, communications, or medical information, are changing. Physicians need to consider how this impacts their practice and their relationships with patients. Doctors are also advised to recognize that professionalism transcends merely responding to patient wishes. In denying requests for unnecessary diagnostic tests or refusing to renew inappropriate prescriptions, physicians can rely on their commitment to professional standards and ethics to guide their decision-making. In this respect, as in many others, the principles of professionalism are more than rules to be followed; they set the parameters to guide informed judgment.
- Truog, R., "Patients and doctors – The evolution of a relationship," New England Journal of Medicine (2012) Vol. 355, no.7 p.583-584
- Australian Medical Association Council of Doctors-in-Training, New Zealand Medical Association Doctors-in-Training Council, New Zealand Medical Students' Association, Australian Medical Students' Association, "Social Medical and the Medical Profession: A guide to online professionalism for medical practitioners and medical students". 2010. Page 3. Retrieved July 2012 from: http://ama.com.au/socialmedia
- Ibid., 7