Since ancient times doctors who take care of the physical pain and suffering of human beings are considered next to God.

The ancient Indian physician Charaka once said, “A good physician nurtures affection for his patients exactly like a mother, father or brother.”

The doctor-patient relationship has long been assumed to be a straight forward association between an expert in medicine and a person in need of medical care.

In modern times doctor-patient relationship has been defined as “a consensual relationship in which the patient knowingly seeks the physician’s assistance and in which the physician knowingly accepts the person as a patient.”

Doctor has to

•   respect the patient’s autonomy,
•   maintain confidentiality,
•   explain treatment options,
•   obtain informed consent,
•   provide the optimum standard of care,
•   commit not to abandon the patient without giving him or her adequate time to find a new doctor.

The building stone of doctor patient relationship is element of trust.

In past, there was no question about this noble service but recently dissatisfaction on doctors raises number of questions. In the last few decades, rapid changes in the health care delivery system in India have resulted in considerable strain on this relationship.

In the early part of twentieth century with evolution of modern medicine maximum doctors in India were general physician or family physician. Maximum of these doctors were practicing in rural area and there were hardly few specialist who were available only in large urban area. These general physicians usually practiced medicine in their own village or nearby area. So they developed a good relationship with the community because they were always available round the clock and they usually discussed with the patients regarding different matters of family rather than usual doctor- patient communication.
They usually knew the health status of all family members of the patient. As a result a good interpersonal relationship was developed between doctor and patient. These family physicians explained to their patients nicely the problems, probable diagnosis, treatment protocol and patient also were able to express their views as much as possible because there was no time constrain in the consultation process. In this process patient developed a trust on the physician. Patient hardly believed that doctor could do any harm to the patient or if sometimes any unwanted condition aroused then patient accept it as God’s will. Society had strong trust on the doctors. These general physicians only referred the genuine cases to the specialist and the cost for consultation was very minimal

CHANGE IN RELATIONSHIP :-

With improved transport and communication physician started receiving patients of all strata from far of places resulting in increase of physician’s load manifold. This resulted into opening of new business opportunities and division of labor in medical care. Pharmacological industry, with marketing, and over the counter availability, took away an important element of physician control over the availability, administration of medication and treatment of patients. The second development was the advent of nursing and nurses were considered as another important pillar replacing the doctors as the sole face of care and empathy in health care. With technological advances, the medical sciences accepted laboratory services for pathophysiology and radio-imaging technology. Thus, the medical profession diluted the direct role of the physician and as a result the patient doctor interface became multifaceted with more and more inputs available to the patient and the physician through the multilayered and nuanced administration of medical care in the postmodern era. In cases of unwanted results of treatment doctors were questioned for their competencies and knowledge which was just like challenging the undisputed authority of doctors in their own fields.

CURRENT SCENARIO :-

In last decade doctor patient relationship has shown a great dip. The forces of increasing economic aspirations, stress levels, frustration due to urbanization, and high levels of competition, distorted and disturbed religious and cultural values are adding to the intolerance among doctors & the masses.

There is sense of distrust toward the medical fraternity. A study suggested that nearly 75% of medical personnel in India have faced some sort of workplace violence. This study concluded that the 50% violent incident took place in the Intensive Care Unit of hospitals. A general feeling of mistrust against medical fraternity is prevalent, doctors are considered as traitor corrupt and money minded. This mistrust has resulted in increased cases of violence against doctor and hospital. Simultaneously, more and more cases of medical negligence are being filed in the court. Many doctors’ practices have been ruined by fake cases with malafide intentions against doctor & hospital. Many famous doctors have hired personal security and hospital had hired bouncers for protection for their security. This has become the new normal in this noble profession. This mistrust is so haunting that many doctors have started propagating a concept that, treat every patient as potential litigant.

CAUSES OF DETERIORATING DOCTOR PATIENT RELATION :-

Health care delivery is either through private sector which is costly and business oriented or government sector which is in pathetic state. Poor access to free or cheap medical care leads to anger and dissatisfaction. Any disease brings a major financial burden on the family especially in villages and low socioeconomic strata people. For any disease patient has to be taken away to nearby city leading to loss of business and selling of property to get treatment. Inadequate doctor patient ratio Because of this disproportionate doctor- population ratio doctor is not able to spend much time which is required.

Inadequate doctor patient ratio

Doctor is not able to spend much time because of disproportionate doctor- population ratio which results in lack of rapport building during consultation process (especially in government setting). Most of the time patients are not satisfied, as a result the relationship is deteriorating day by day.

Expansion of literacy and awareness

With the increase in literacy rate patient and their relatives are now more aware regarding their rights. Patient and their relatives now ask questions on doctor’s unrealistic behavior as a result the relationship deteriorates.

Easy accessibility to information

With advent of Information Technology patients are empowered with information.

“Blind trust is being replaced by “informed trust”.

More and more patients take help of internet for self-diagnosis or test the competency of doctors, which may be dangerous. This breeds mistrust. Now Patient desires to become a part in the decision-making process which is his right. Traditionally the ideal doctor-patient relationship was paternalistic; doctors direct care and makes decisions about treatment. Now patients and their relatives want shared decision making. Many of the time it has been found that correct informed consent has not taken before costly investigation or invasive procedure.

Consumer protection act 1986:

This act has done more harm than good for medical profession by putting healthcare services under consumer protection act. Many a times this was misused by patients for their benefits and threatening the doctors and hospital owners. This has made doctors more defensive and forced them to take approach of evidence-based medicine thus tremendously increasing the cost of treatment.

Private Medical Colleges

Students have to pay huge “donations” to get into the rapidly increasing number of private medical colleges and to get on to sought after postgraduate courses. This produces a great impact on the attitude of the doctor when he starts practicing medicine. In want of early money, doctors start working for multiple hospitals or gets into the game of commission with pharmaceutical companies, to regain their investment. This greed for extra money among the doctors at times results in to malpractices which brings disrespect to the profession.

Corruption & negligence in Government Health System

High level of corruption in the Government health care industry is one of the important causes of deterioration doctor patient relationship in India. Number of scams in NRHM is destroying the reputation of doctors. Those who can pay are able to enjoy highest level of health care while majority of the poor and middle class have to depend on poorly developed government health care system. Because of this inequity in health care delivery system all the anger and frustration of the poor patient and their relatives go against the doctors (soft targets) and they become hostile and violent.

Private Hospitals:

Some private hospitals are keeping patients unnecessarily in the I.C.U for extra charge.

Entry of corporates results into commercialization of health care by merging medical care with hospitality (hospital with hotel facilities) which has made the thing worse. People pay more and expect more. During illness the feeling of suffering has gone and replaced with feeling of value for money and comfort. Technological development in medical science India has seen rapid development in medical care scenario. Excellent development has occurred in the laboratory technology, diagnostic and therapeutic services.

Specialists and super specialists

Specialists and super specialists have started dominating India’s health care. All this leads to very high and unrealistic expectations in patients and relatives mind. When there is a difference between the expectation of the patient’s relative and ground reality, it outbursts in the form of mistrust anger and violence.

Health Insurance:

Expanding middle class population and growth of health insurance Hospitals had taken advantage of more paying power of patients and insurance as easy money. With these trends people are ready to pay even higher amount for treatment and saving lives of their beloved. In return they are expecting best possible services. Poor services or any type of negligence flare-ups the emotion of patients and relatives.

Workplace factors:

Workplace factors such as communication barriers, physical barriers, political pressure, the influence of relatives, and heavy workload adversely affect the relationship.

A LOST BATTLE SITUATION FOR BOTH SIDES:

Directly or indirectly both parties are at loss and neither doctors nor patients are happy with present situation. Grievances are from both side and increasing day by day. Doctors become more and more defensive in their approach and treat on the basis of clinical test with clinical acumen taking a back seat. This leads to increase in costs of treatment which cause more frustration among the patients. Not many doctors are ready to take challenging cases in which there is risk of bad result. The mismatch of doctors and patient expectations or society at large is very much prevalent and is major road block for this situation.

Doctors have to understand that they are not supreme who cannot be questioned and Society have to come to an understanding that doctors are not God and they are just using their learned skills for the betterment of patient. The fee of doctor is not only the value of time but also the value of their expertise which they have learnt after a hard work of long tenure of study.

Recognition of Doctor

The health care system still recognizes doctor as the top most person governing the type of care given to patient. But they have to learn the new normal. They have to accommodate themselves in this litigant world with careful practices, take adequate measures to build up trust of patient and involving patients in planning their treatment decisions (cafeteria approach) wherever possible.

WAY FORWARD

  To improve this scenario both doctors and patients should introspect their behavior.

  Professional bodies, patients and social activist all should debate and find out the solutions.

  Doctors should try to understand the sociology & psychology of the patient and his relatives.

  Doctors should take a little more time in talking, in reassuring patients in the old-fashioned way, communicating the risk of disease & benefits of treatments, involving patient in decision making.

  Patient and society have to understand that doctors although professional do have responsibilities towards their family. They chose this profession not just for social service but, for making their carrier and earn money for their bad time and fulfilling family obligations.

  Nothing comes free in this material world and to give free and cheap treatment in this time is not doctor’s responsibility but the responsibility of government.

  Patients and society have to show regard and honor for doctors so that they can work in threat-free environment which is only for society’s benefits.

  Every field has black sheep and law should deal with those law-avoiding people.

  Government should make policy for easy access of good health care facility even for downtrodden and weaker section of society and it should never be available only for rich.

  Government should effectively implement laws to prevent violence against doctors.

  It is for the betterment of all stakeholder to understand the need of hour. Till then doctors have to be patient and work on phrase 'Physician heal thyself‟