Doctors’ relationship with patients and their role in society is changing. Until the 1960s doctors concentrated on the welfare of patients with less emphasis placed on patients’ rights¹. Over recent decades there has been increasing empowerment of the individual across all facets of society including health care. Doctors continue to be perceived as having expertise and authority over medical science. Patients, however, now hold sway over questions of values or preferences. We all must be aware of this change in the doctor- patient interaction. We need to be more aware of the outcomes that patients view as important. The concept of shared decision-making with the patient is now widely appreciated. The process involves a change in mind set particularly for doctors who trained in an earlier era. 

Doctors have always found communication with patients difficult. Communication short comings are one of the main reasons that patients complain about doctors. We are not so good at making the most of what we are. This is to some extent understandable. The news for the patient may not be good. There may be uncertainty about the diagnosis or we may be unsure about the patients’ long-term well-being. Often doctors simply want to be nice and are trying not to upset the patient and his family too much particularly at the outset of a serious illness. In the publication Effective Communication Skills for Doctors² the authors point out some of the common failings. Non- verbal skills are increasingly being emphasised. One must maintain eye contact, avoid looking through notes or at the computer screen during the consultation. Ask the patient what he/she needs from the visit and explain what can be covered. Failing to listen or offer sufficient explanation remains a frequent complaint. When patients are concerned it is advised not to offer premature reassurance, switch the topic or jolly the patient along. Teaching these communication skills is being increasingly being emphasised. When discussing any medical condition with students it is essential to demonstrate to them how to impart the diagnosis to the patient in clear language that they can understand. It can be difficult for students and trainees to find good role models as their bosses were never formally taught communication skills. 

Patients retain the right to either modify or refuse their treatment being offered to them. It is much more uncertain as to whether doctors are justified in refusing patients who request items of care that are considered clinically inappropriate. Medical teams have great difficulty about the ethics of administering treatments that have a low chance of success. Some states in the US permit doctors to refuse such treatments. In Ireland there is lack of clarity on how to proceed when patients make irrational choices. It is clearly important to get it right. Getting second opinions and involving the allied health professionals including social workers and psychologists at the outset is advisable.

The standard teaching of doctors is that their efforts must be exclusively focussed on the patients without consideration of the financial costs. While this should remain the goal for the individual patient, the medical profession has to be involved in the global costs of healthcare both at a local and national level. Unless one examines the wider issues, the delivery of medical care will be fragmented with some groups doing well and others being poorly served. Troug¹ describes this as the balance between personal advocacy for one’s patients and the obligation to use healthcare moneys in the most effective way. The 2012 manual of the American College of Physicians³ states that physicians have a responsibility to practice effective and efficient health care and to use resources responsibility. The new phrase is ‘parsimonious care’. It points out that there are many examples of poor value for money including nonadherence to guidelines, expensive variations in clinical practice and unnecessary hospitalisations⁴. Resources are finite and doctors are well placed to identify the priorities in terms of expenditure. In order for this model to work, doctors must be prepared to be actively involved in the administration of their departments and administrators must include them in the decision making process.

The delivery of healthcare has become highly political and is constantly under media scrutiny. Doctors are invariably drawn into the debate. In addition to the traditional TV, Radio and Print media there is Twitter, Blogs and Facebook. The GMC, in relation to media involvement, states that doctors must make sure that their conduct justifies the public’s trust in the profession. They must be mindful of patient confidentiality and treat colleagues with respect. When it comes to social media, the question being increasingly asked is whether doctors have a private life⁵. Where is the dividing line between one’s professional responsibilities and the freedom to communicate with friends on internet outlets. The answer is unclear. 

For example, is what one pastes on Facebook one’s own business and has nothing to do with one’s professional life? Apparently this is not the case. The worry is that people in general tend to feel disinhibited when they go online. This increases the likelihood that the content could later be deemed inappropriate or that personal information about a patient could be unintentionally released. The posting of any information about one’s medical work on Facebook could come under adverse scrutiny by employers at a future date.  On the other hand, there needs to be a common sense balance. European citizens are protected under law which allows them to have private lives. It would be a pity if doctors had to retract from full participation in society merely because of disciplinary fears.

The medical profession must be continually open to change in order to fully embrace the demands and needs of modern society. On the other hand the public must appreciate that the modern doctor is more informal, more media interactive but remains very professional.
JFA Murphy
Editor

1.Truog RD. Patients and doctors-the evolution of a relationship. N Engl J Med 2012;366:581-4.
2. Parrott T, Crook G. Effective communication skills for doctors. BPP learning media 2012.
3. American College of Physicians Ethics Manual. Sixth edition. Ann Intern Med 2012;156:73-104.
4. Neumann PJ. What we talk about when we talk about health care costs. N Engl J Med 2012;366:585-86.
5. McCartney M. How much of a  social media profile can doctors have? BMJ 2012;344:18-19.