Perception of Doctor-Patient Relationship in the Present Time from the Viewpoint of Doctors: A Qualitative Study at a Tertiary Health-Care Center in Eastern India.

CONTEXT: Doctor-patient relationship has gone through some troubled times in the recent past. Quality data regarding this is lacking in the Indian setting. AIMS: The study aim was to find the perception of doctors regarding doctor-patient relationship. SETTINGS AND
DESIGN: The study was conducted at a tertiary health-care center in West Bengal. It was a qualitative study including in-depth interviews and focus group discussions (FGDs). SUBJECTS AND METHODS: The study comprised of in-depth interviews (IDI) of thirty residents and three FGDs, involving 33 residents. STATISTICAL ANALYSIS USED: Data analysis was performed manually by deductive approach. Descriptive "codes" of the text information were done. The consolidated criteria for reporting qualitative research guidelines were followed.
RESULTS: Doctor-patient relationship was perceived as of mutual trust and respect. Overburdened doctors, impatient patients, unrealistic expectations from the treatment, and lack of infrastructure were some of the agreed-upon factors for the strained relationship. A combined corrective effort is needed to salvage the current situation.
CONCLUSIONS: A healthy doctor-patient relationship is instrumental in the holistic picture of health care. Doctors, patients, administration, and media have shared causation to the problem and have equal responsibility for its amendment. Copyright:

INTRODUCTION

Doctor–patient relationship has been hailed as the mutual trust, confidence, and a shared sense of goodwill. Doctors have been considered as god's apprentice and divine healers in the past. Over time, the dynamics of the society has changed.

In most of the developing and some of the developed countries, a major percentage of health care is still privatized and patients with major illnesses often go through financial crisis coping with the cost of illness. With the population explosion, the doctor–patient ratio has dropped.[1] Most of the doctors are overworked and fail to give the necessary time on per-patient basis.

All this and many other factors have contributed to loss of trust in doctor–patient relationship. It is strained in the present times, with more and more cases of violence against doctors being reported. The number of medical litigation cases has snowballed and people are getting less and less tolerant toward even minor complications. This has taken a toll on the physician's mindset, and health-care providers are getting less empathetic to patients. This vicious cycle of events has led to the present scenario.[2]

The doctor–patient relationship has been categorized into four key processes by Razzaghi and Afshar,[3] which includes valuing the patient as a person, management of power imbalance, commitment, and the physician's competence and character. This, in turn, leads to three important elements of trust, peace and hope, and being acknowledged.

In another study,[4] it was found that doctor–patient relationship is very important in the medical context, but when distorted, it can lead to bad outcomes. A distorted system and lack of infrastructure were identified as the main culprits for the strained doctor–patient relationship. Another study by Ridd et al.[5] showed that doctor–patient relationship evolves through a process of longitudinal care which focuses on one doctor seeing a patient every time and following up and a patient's experience of his/her initial consultancy with the doctor.

As is evident, a patient's perspective is very different from that of doctors as his/her focus is on establishing an emotional bond with the doctor.[678910] This theory was strengthened in a study done in Denmark[11] which showed that the patient develops an emotional relationship with the doctor, and he/she feel a certain sense of vulnerability in their relationship.

In India, we have unique cultural, social, political, and economic dynamics which may affect the doctor–patient relationship in a unique way.

In this study, we intended to know the perspective of doctors about the doctor–patient relationship in the present time, the problems they face, and the possible solutions from their viewpoint.

We used qualitative analysis as we desired a detailed and in-depth perspective of doctors about this issue. It was done by the help of a series of in-depth interviews and focus group discussions (FGDs) among resident doctors of different specialties from the same hospital. Ethical approval was taken from the institutional ethics committee for the study.

SUBJECTS AND METHODS

The study was conducted in the urology department of a tertiary care center of West Bengal. The study was one of the qualitative descriptive types involving in-depth face-to-face interviews (IDI) of thirty residents and three FGDs involving 33 residents of different streams of the institute. The participants were selected purposively and requested to participate in the study. All the interviews were conducted at a convenient place after taking consent by the first author. Before the beginning of the study, a structured questionnaire was prepared by the authors after thorough literature review.

All the interviews were conducted in a convenient place, and each interview lasted for 10–15 min. No repeat interview was conducted. All the interviews were conducted mostly in English language; however, a few of the participants used Bengali and Hindi languages during the interviews.

Audio-recording of the interviews was taken.

In the first FGD, there were a total of 12 participants; in the second FGD, there were a total of 11 participants; and in the third FGD, there were a total of 10 participants. All the participants were well informed about the purpose of the study. All the questions used during the interview were open ended. The data collection process continued until a saturation level was achieved (no new information was present). The interviews were transcribed and typed into English. The data analysis was performed manually by deductive approach. Descriptive “codes” of the text information were done. The consolidated criteria for reporting qualitative research guidelines were followed. The script was written. It was reviewed and revised by other authors. Finally, the script was prepared for publication.

RESULTS

This study was conducted in 2018 over a period of 6 months at a single tertiary care center in West Bengal. All the participants were resident doctors. They have 10–12 working hours every day and interact with an average of fifty patients daily including outdoor, emergency, and admitted patients. They have first-hand experience of talking to the patients' relatives and get to know their expectations and disappointments in the most unadulterated form.

Our first question was about what they feel the doctor–patient relationship is all about. Some of the responses were:

It is a matter of individual interdependence between a doctor and his/her patient. The trust between them is for the good being of the patient

It is about trust and respecting each other

It is about having open communication, mutual trust, and not just a business transaction as the society makes it out to be

Doctor–patient relationship should be like family members and there should not be any obstacle in it by surroundings.

As is evident, most of them perceived doctor–patient relationship as mutual trust, understanding, and much more than just a “business transaction.”

Our next question was what they think the relationship is now in the present day. There was a unanimous consensus that the relationship is severely strained at the present time. There is general lack of trust among patients. Doctors on the other hand are also overwrought by the mistrust and violence against them.

In continuity, the next question was what they think of the possible reasons about this strained relationship?

We categorized all responses into four basic categories. First, factors related to doctors, followed by factors related to patients, factors related to infrastructure and administration, and finally the role of media.

In factors related to doctors, we had different responses which were divided into different codes. The reasons included were immense work pressure on doctors, lack of communication by doctors, and events of malpractice done by some doctors.

Factors related to patients included unrealistic expectations on the patient's part, half-cooked knowledge gained through the Internet, lack of awareness and understanding about the disease and treatment, and lastly lack of loyalty and regard toward doctors.

Factors related to infrastructure and administration were serious concerns, expressed by everyone. Poor infrastructure at most centers with severe shortage of workforce is the most important reason for patients' suffering and agitation.

The role of media was a recurring finding, and everyone emphasized on how they are playing a large negative role.

Our last question was about possible measures that can be taken to improve the situation. We had several responses as follows:

“To save doctors to save life” should be the motto for the society

Improving the working conditions by proper duty hours. Counseling of the patient and giving clarifications properly. Not openly criticizing fellow doctors

The administration should provide round-the-clock security for the doctors. Improvement of workforce and availability of lifesaving medicines at all time

Doctors should be polite, should be well mannered, and should have good communication with patients. They should explain the situation and possible outcome with limitation of doctors

Media should be regulated from broadcasting wrong information

Rules should be implemented for strict action against the harassment of doctors.

DISCUSSION

The doctor–patient relationship is strained and hanging by its last thread at the present time.[12] Violence against doctors is at all time high,[13] and doctors are losing empathy.

There are multiple factors responsible for this strained relationship. Doctors have an immense work pressure allowing them to spend very little time with their patients.

Patients, on the other hand, have now developed mistrust issues, largely due to lack of awareness of their condition. This has been worsened by the general tendency to gain quick knowledge from the Internet.

As in most developing countries, administration in our country is largely failing to provide adequate health-care services to the masses, mostly due to a large population and inadequate infrastructure. This has resulted in agonizing queues, long waiting line for surgeries, lack of essential medicines, and inaccessibility of a quality health-care provider for a large segment of population.

Over the last decade, due to the big bang in the world of television, the Internet, and telecommunication, the world of journalism has taken the colors of green and yellow. Sensationality is the new motto, and health care has taken the brunt of this demon. Most of their “stories” are ill researched and half cooked and have created more havoc than awareness.

As we looked for answers, they were hidden in the problem itself. It was emphasized that doctors need to improve their communication skills as it is the key to the whole process of building a healthy relationship. The new MBBS curriculum entails a foundation course[14] for this purpose. It includes skill development in language, interpersonal relationships, communication, and time and stress management. Patients, on the other hand, have the responsibility to be aware and educated about their condition. They share an equal responsibility.

Government and local authorities have the responsibility to ensure adequate infrastructure. They have this mammoth task ahead of them to ensure healthy doctor-to-patient ratio in the population.

Last but not the least, media should be more responsible and selective in their reporting of events. This age will demand a “save the doctor” campaign if the current state of affairs continues to grow on.

The strength of this study is the qualitative, in-depth inquiry into the problem with over fifty participants. The problem was discussed initially by one-to-one interaction in the interviews and later on, by FGDs, which allows crossing of data. In FGDs, some of the ideas were agreed upon, whereas others were seen as unworthy and discarded.

The major limitation of the study was the fact that it was done in a single hospital and there are some local factors in play which are not applicable everywhere.

Even with this limitation, we feel that the findings are transferrable to most of the population in India.

A healthy doctor–patient relationship is instrumental in the holistic picture of health care.[15] Doctors, patients, administration, and media have shared causation to the problem and have an equal responsibility for its amendment. There is nothing which cannot be undone by mutual effort.

In the words of Robert Schuller, “problems are not stop signs, they are guidelines.”

Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.