Doctor and patient

The ideal doctor-patient relationship should be a partnership: the patient gives information that enables the doctor to use his professional skills to best advantage, and the patient then provides feedback so that they can both assess what has been achieved. For best results there should be mutual trust and respect. It is as important for the patient to do exactly what the doctor suggests as it is for the doctor to listen to what the patient wants or has to say. Also, it is important to bear in mind that a patient always has the right to choose and to change his doctor – although the doctor also has the right to refuse any patient he does not want to have on his list. However, because the doctor’s expert knowledge enables him to speak with authority, it may be hard for a patient to say what he thinks is important or to maintain a point of view with which the doctor disagrees. It seems difficult for some doctors not to take a somewhat paternalistic attitude. They are aware that when someone is unwell, his judgement may be clouded. And they know from experience that the patient may be running risks of which he may be unaware; side-effects of drugs and treatments, for example, may be detrimental to health unless the patient complies precisely with the instructions.

Abdicating responsibility?

Many people find it reassuring, especially if they have been contending with a particular worry or with unpleasant symptoms, simply to put themselves into their doctor’s hands. They trust him to do what is best and accept unquestioningly whatever treatment is suggested. Sometimes, a patient may be nervous, or so in awe of his doctor’s professional status, that he is unwilling to query anything the doctor tells him. Unfortunately, some doctors encourage this attitude, rather than developing a more frank exchange of information.

Other people prefer to retain a measure of control in their treatment, and take at least an equal part in any decision that has to be made. The doctor can give advice, but he cannot force the patient to take it, except under very special circumstances – for instance. If the patient has a contagious disease that might infect other people, or when a mental illness is so severe that treatment must be enforced either for the patient’s own safety or that of others. If a patient is unhappy about the doctor’s diagnosis, or the course of action he suggests, the patient should not feel he is insulting the doctor by saying so and perhaps seeking a second opinion. No doctor is infallible and few medical decisions are black or white; it is therefore entirely reasonable for the ‘consumer’ to seek as much advice as he feels he needs about a matter as important as one’s health. A patient may want to know more about the treatment suggested before he decides whether to accept it or not. What are its risks and benefits? What is its likely final out- come? Are there any long-term effects? These are not unreasonable questions when health, is at stake.

Visiting your doctor

Remember that a medical consultation involves an exchange of information. On the patient’s own part, before he visits his doctor, making a written list of his symptoms and his complaints may be helpful. It is best if these are as specific as possible. ‘Pains in the abdomen’ is not that helpful; try to decide how long these pains persist, whether they are there all the time or only after meals, the location, whether the pain is sharp and stabbing or a dull ache, and so on. If the doctor does not already know, it is sensible to tell him whether you are suffering from any other condition or are currently taking any drugs, because this might influence the diagnosis or treatment. Most people are very conscious of the pressures on their doctor’s time, but it is important to take the opportunity during consultation to ask questions. It may be a good idea beforehand to write a list of the questions you want to ask, in order not to be flustered into forgetting them at the time. Sometimes, answers given by the doctor are not understood fully. Any medical matter can be explained in lay terms. If this takes too much time during the first consultation, it might be a good idea to make another appointment that is reserved for an explanation of the diagnosis and treatment. Studies have shown that, in most cases, patients fail to grasp at least a part of the doctor’s diagnosis, sometimes understanding as little as 50 per cent. It will be evident that it is important for a doctor to know whether he has been properly understood, especially if he has explained a delicate therapy. For this reason many doctors ask the patient to repeat what he has been told.

Confidentiality

Except in a few special circumstances, a doctor will not divulge anything told to him to anyone who is not involved in the treatment of the case. There is a legal imperative for him to maintain such confidentiality. Hospital records and case-notes are confidential, and special precautions are taken to ensure confidentiality in such sensitive areas as psychiatry or venereal disease, such as syphilis.

However, there are occasions when medical confidentiality has to be breached for legal reasons. If a patient is suffering from a highly infectious condition, for example, or is addicted to heroin or certain other drugs, a doctor has a statutory duty to report this. And a judge may demand that a patient’s medical notes are made available to the court if he believes they contain information relevant to a case.

Patients’ right to information

Confidentiality is generally well maintained in medical practice. But what rights does the patient have in terms of access to his medical record? Although he has a right to information about his condition he has no legal right to see his medical notes – they belong not to him, but to his family doctor, or, if he is receiving specialist treatment, to the local health authority. There is a growing debate about the desirability of keeping medical records from patients, fuelled in part by patients themselves wanting to take a more active role in their treatment. The danger of keeping medical records secret is that, although doctors are trained to be impartial in assessing a patient’s condition, personal prejudice can creep in that remains on that person’s record to his possible detriment. Sometimes, if a patient has a serious or potentially fatal illness, the doctor may discuss with the patient’s relatives whether or not the patient should be told. Usually, a doctor takes his cues from the patient, and assumes that if the patient asks questions about his condition or its outcome, he genuinely wants to know and so should be given an honest answer. If a patient asks no questions, the doctor will probably not volunteer any information that he thinks would distress the patient. Telling the truth, but not the whole truth, is an acceptable compromise in such situations.