THE MEDICAL RELATIONSHIP PATIENT

The relationship between doctor and patient plays an important role in the practice
of medicine and It is essential for the provision of high quality health care in terms
of diagnosis and treatment of disease . The relationship between doctor and patient is one of
the bases of medical ethics contemporary. Most medical schools teach their students from the
outset, even before they begin to receive practical medical instruction, to maintain a
professional relationship with their patients, observing their dignity and respecting their
privacy.

1. IMPORTANCE

The patient should have confidence as to the competence of his physician and should feel that
they can confidently confide in him. For most physicians, establishing good contact with the
patient is important. There are some medical specialties such as psychiatry and family
medicine , in which more emphasis is regarding the doctor-patient than others such as
relationship pathology or radiology .

The quality of the relationship between the doctor and his patient is important for both
parties. The better the relationship in terms of mutual respect, knowledge, trust, shared values
and perspectives on disease and life, and the time available, the better the amount and quality
of patient illness information to be exchanged in both Directions, improving the precision of
the diagnosis and increasing the patient's knowledge about the disease or illness. In those
circumstances where the relationship is poor, the physician's ability to perform a complete
patient assessment is compromised and the patient is more likely to be suspicious of the
diagnosis and proposed treatment, reducing the chances of complying with medical advice. In
these circumstances, and in cases where there is a genuine difference in medical opinions, a
second opinion may be obtained from another physician or the patient may decide to change
doctors directly.

2. MODELS OF MEDICAL RELATIONSHIP PATIENT

In the care of the sick we have pointed out, a primordial aspect is the doctor-patient
relationship, whose foundations are found in the very principles of bioethics. The doctor-
patient relationship is the contract, usually not written, established by autonomous persons
free to start, continue or break this relationship.
In the patient's interaction with the doctor and the health team, based on communication and
willingness to achieve common goals, such as disease prevention, preservation and recovery
of health, rehabilitation and reintegration into the family, social and in labor occasions, there
are several models of doctor-patient relationship; four are the most important and commonly
accepted.

2.1. Paternalistic model

In which the authoritarian attitude of the doctor who directs the actions prevails, indicates and
/ or performs the therapeutic diagnostic procedures, whereas the patient only complies with
the indications, without taking into account his opinion, doubts or fears. It is a subject-object
relationship in which, although it is a question of benefiting the patient, their autonomy,
freedom, capacity and right to decide are not respected. This model is prevalent in Mexico
and Latin American countries, especially in rural areas.

2.2. Dominant model

In contrast to the above, it is the patient who, according to his knowledge or the information
obtained, asks or demands that, according to the established diagnosis, certain diagnostic-
therapeutic procedures be performed. It is a subject - object relationship that usually occurs
when the treating physician has little experience. In these cases abuse of autonomy of the
patient can be harmful

2.3. Model of shared responsibility

In this model, good communication is established, the patient and the family are informed
about their illness, diagnosis, treatment and prognosis, as well as the possibility of
complications. Their doubts are clarified and their fears are dispelled; the alternatives are
discussed and jointly the best decision is made. In this model, the patient's autonomy, freedom
and judgment intervene in relation to what he wants or what he expects, all under the
guidance of the attending physician. It is a subject-subject relationship, so it should be
desirable to try to implement it.

2.4. Mechanistic Model

In it the attention is carried out in accordance with strict administrative provisions; rigid
management protocols are followed, the patient does not choose the treating physician and is
not always treated by the same physician, which interferes with the doctor-patient
relationship. The excess of bureaucracy and administrative procedures slows the treatment
and deteriorates the relationship, which is subject-object type.

This model is frequent in institutional medicine, although it also occurs today in the care
provided by service providers and insurance companies.

The termination of the doctor-patient relationship can be due to the lack of collaboration of
the patient or his / her relatives, lack of empathy or incompatibility in their moral values,
physical or technical impossibility of the physician to care for the patient, lack of material and
human resources for Adequate care, interference of relatives, responsible person or other
doctors, explicit request of the patient, relatives or the doctor himself. In institutional practice
there are limitations and special circumstances, specified in contracts or agreements with
companies or insurance companies that terminate the relationship.

3. CHANGES IN THE PARADIGM

Until the beginning of the 20th century, the doctor counted to make the diagnosis of diseases
with a fundamental element: the interview with the patient. This peculiar relation of
confidence of the patient and understanding of the doctor, was completed with a detailed
procedure of physical examination of the patient that was not limited only to the region of the
organism that seemed affected. As a diagnostic assistant, the physician at that time had a
limited number of laboratory tests and simple radiological studies.

At present diagnostic resources have increased considerably. Laboratory tests are counted per
hundred. The auxiliary cabinet methods that started with radiology today offer Computed
Axial Tomography, Magnetic Resonance. In endoscopy today it is possible to explore
practically all the cavities of the human being.

As for the treatment of diseases the change are the great advances of therapeutics with
medicines and innovations and creation of techniques in surgery.

With all these advances, today's medicine would be glorious if it had not inserted into it
disturbing elements that bring about changes in the traditional paradigm of medicine and the
doctor - patient relationship.
We must recognize that there are two completely different aspects in these changes. One of
them highly positive and another negative that can invalidate the great advances mentioned
and generate the loss of the values of yesteryear.

Positive change refers to the progress towards a social medicine, for the benefit of the
community, organized to serve all the inhabitants of a country or a group of them.

The negative change of the paradigm is the conversion of an eminently humanistic profession
and of social benefit to a medicine conceived as an industry, where one must seek the benefit
of the investors who have created this industry.

In positive change, there are also differences, some countries have developed it through large
public institutions, organized by the state for the attention of the inhabitants.

We must accept that somehow the great advances in medicine have led to its conversion into
an industry. The resources for diagnosis and treatment are so numerous, costly and complex
that they have surpassed the ability for only doctors to organize care centers.

All of the above has changed the paradigm: to be a profession of social benefit, which does
everything only for the sake of the sick, and with the great scientific and technological
advances that today have could do better, But that with the change of profession to industry, it
annuls the great advances, since these are limited to certain strata of the society.

4. CIRCUMSTANCES INFLUENCING THE MEDICAL-PATIENT

RELATIONSHIP
4.1. Of the doctors

The working conditions of the doctor are clearly different from those that existed in earlier
times. Today it tends to be an employee in public and private institutions, to work amid
shortages and discomforts.

The salary is insufficient to solve personal and family needs which forces us to have several
jobs, which influences efficiency.

But in addition, the demand has increased on the part of the patient and the society, in such a
way that the work of the doctor is carried out with the permanent threat of demands and
claims.

Peer regulation has been present in medical care. The councils of specialty try to watch that
those who stand as specialists reach the technical and ethical standards that society requires.
The doctor of today has to maintain its current certification and to comply with academic
requirements.

The doctor's public image has also changed in relation to what he had in the past. Today he is
identified as a health worker, a wage earner, but as a bureaucrat. It has lost credibility among a
segment of society, in such a way that the doctor-patient relationship has been filled with
mutual mistrusts that foster a vigilance of the physician's performance by the patient, his
relatives or his lawyers. It is also not unusual for them to request a second or third opinion.

Teamwork is nowadays weighted as a desirable formula to practice clinical medicine, which

seems less and less a matter for a single doctor and his patient. In health care units it is often a
different doctor who cares for the patient at each appointment. When the equipment is not
well integrated the patient can receive different or even contradictory information from each
of its members.

4.2. From the patients

The patient has gained a greater awareness of their rights and is increasingly frequent to
defend their capacity for self-determination with the support of the family. Modern bioethics
enshrines the principle of autonomy for competent patients, so it is accepted that they may
even refuse to follow the prescriptions of the physician if they do not seem appropriate and
supports the patient's right to participate actively in the decisions that concern him.

The epidemiological transition has favored the accumulation of patients with chronic diseases
and it is in these cases when their participation is paramount and the initiative of control and
management has the patient, who must know what to do in the face of various circumstances
that he has already had to live and experience. The role of the doctor is an adviser and
educator who allows the patient to make decisions.

On the other hand, society has become distrustful of anything that smells of authority, whether
it is the formal health or the one represented by the doctor. Each provision is subject to
questioning and a good part of demands occur as a result of poor information.10

4.3. From the environment

The role of modern technology is difficult to calculate, but there is no doubt that it has
influenced the doctor - patient relationship.
The physician in whom he has atrophied, the art of the clinic suffers from operative paralysis
in the absence of the machine-artifact that supports it. Medical care has increased its costs, by
the use of technology as complex as by the flourishing of the "health business." It should be
stressed that these higher costs do not depend on whether doctors have higher fees or salaries.

The economy has invaded the health field, since it has to be profitable, the profits benefit
many people today and not always the doctor and the patient, which are eventually used. The
systems that administer medical care are not always focused on quality in its broadest sense
and although they have multiplied, they have not achieved greater efficiency.