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Despite strong evidence over time of the clinical, psychological, and emotional benefits of strong doctor-patient relationships, these relationships are transforming quickly due to a “new normal” within health care delivery of de-emphasizing patient contact with the physician; using disruptive innovations that emphasize transactional speed and convenience in service delivery; and pressures exerted by external forces like the overuse of performance metrics. Strong doctor-patient relationships are characterized by dyadic interactions over time that feature high degrees of trust, empathy, listening, and emotional support. As the notion of “relationship” in health care moves from doctor-patient to organization-patient, it is important to gain insights about the present and future of relational care through the voices of doctors and patients describing their interactional experiences, and how these experiences shape their thinking and behavior with respect to each other.

According to the latest Pew Internet and American Life Project, 80% of adult Internet users seek health information from the Internet. Patients who search for cancer-related Internet information differ considerably from those who do not. Studies of mixed groups of cancer patients find that patients who do search for Internet information tend to be younger, own a computer, have Internet access at home and have a higher education level than cancer patients who do not search for cancer-related Internet information. Cancer-specific support groups were first reported in the 1970s, but the number of patients with cancer who are turning to the Internet for support and the number of Internet-based cancer support groups has risen dramatically in recent years. This chapter discusses the benefits and drawbacks of cancer-related Internet information, the impact of the Internet on the doctor-patient relationship, and communication about Internet information. It also presents guidelines for improving clinician-patient communication about Internet health information.

This chapter explores aspects of doctor–patient encounters including patient choices and expectations, the financial implications of the patient–doctor encounter, and the doctor's evolving patient constituencies. It highlights the general practitioner's developing role as a gatekeeper who controlled access to benefits of various types. The chapter begins with a discussion of the likely options facing sufferers in what was an unusually open market for health care. Professional survival in a situation where registered doctors had little, if any intrinsic competitive advantage in recruiting patients, meant that doctors needed to work at improving their accessibility to potential patients, whilst at the same time broadening their social appeal through effective communication, or a good ‘bedside manner’.

We are moving quickly toward a corporately controlled, transactionally focused health care delivery system, one that sees patients as “consumers.” Retail thinking continues to take hold in the industry, emitting a rhetoric that promises much and places the organization at the center of the patient’s interactions with the system. Preserving strong, effective doctor-patient relationships in the midst of such change requires the medical profession to focus more on relational care in its training and advocacy; raising the importance of relational features such as trust and empathy in performance measurements and incentive plans for doctors; and trying to “monetize” relational care between doctor and patient in ways that make health care delivery organizations and the industry as a whole want to focus on it more as a source of brand-building and consumer loyalty.

The centrality of the doctor–patient relationship in medicine is highlighted. Its inalterable central feature is the complementarity of one who needs healing with the other whose function is to heal. Various taxonomies and models that have been proposed to describe this relationship are presented. It is suggested that the basis of the clinical relationship can be understood by considering the conceptual differences between a contract and a covenant. The point is made that there is no universally accepted gold standard for an ideal doctor–patient relationship; the relationship should accommodate differing personal values and beliefs. The nature of attentive listening, and its crucial role in establishing and maintaining a relationship, is discussed.

Doctors view the best relationship with patients in highly personal and idealistic terms, admitting through discussion of their own experiences that sustained interpersonal relationships with many patients are difficult to establish. For doctors, interpersonal trust with their patients looms as the central feature of strong, effective relationships. The ability to relate to patients on deeper psychological and emotional levels was the key focus for them in their work. They also cited other roles, such as friend and expert advisor, as important in gaining patient trust. Doctors’ views and their best patient relationship experiences emphasized the benefits of dyadic care delivery, even as the notion of the relational dyad finds less support within health care, given over instead to higher volume, transactionally oriented care relationships between organizations and patients.

The doctor–patient relationship can be subdivided into four steps. The first is “feeling sick,” a key starting point that triggers the subsequent behavior. It involves sensory systems that generate conscious awareness, and indeed the perception of a symptom, like pain, is the product of bottom-up and top-down processes. The second step is “seeking relief,” a kind of motivated behavior which is aimed at suppressing discomfort. The third step is “meeting the therapist,” a special and unique social encounter whereby the therapist represents the means to suppress discomfort. Here many mechanisms are at work, such as the patient’s trust and hope and the therapist’s empathy and compassion. Finally, the fourth step is “receiving the therapy,” the final act of the doctor–patient interaction. The mere ritual of the therapeutic act may generate therapeutic responses (placebo responses) which sometimes may be as powerful as those generated by real medical treatments.

Cancer progression is not affected by placebo treatments; however symptoms can be reduced by placebos. Nocebo effects are crucially involved in anticipatory nausea and vomiting before a cancer chemotherapy session, with a basic mechanism of classical conditioning. In sports medicine, physical performance in sports activities is boosted by placebos and this poses some important ethical questions about doping. Placebo surgery may induce improvement as well. However, surgical clinical trials with placebos raise many ethical questions. Some alternative and complementary therapies, like acupuncture, have both a specific effect and a big placebo component. It is also important to realize that placebo and placebo-related effects represent a good model for the better understanding of the mechanisms underlying the patient-provider interaction.

This chapter discusses the changing concept of the ideal physician. It begins by presenting four points in relation to the changes in the character of physicianship, before moving on to discussing the effects of science on the ideal of the doctor, the impact of technology as distinct from science, and the changes in the doctor–patient relationship. The chapter also looks at the increasing interest in medical ethics and the concept of commercialism.

The Foundation of the Healing Relationship of Patient and Clinician: An illness is a tale of an individual unique life being lived in its quotidian detail, complex interpersonal activities—work, marriage, parenthood, aspirations and purposes—and how a pathophysiology interferes. The importance of the narrative is discussed. This chapter is about listening attentively—what that is, how it is done, and what it is used for. Listening is necessary to know about the illness, the patient, and the illness experience. Listening is most effective when healer and patient are connected through the relationship. A thorough discussion of the relationship is given. Also discussed are the effect of the healer and the relationship on the universal burdens of serious illness—fear, ignorance, uncertainty, and diversion of purpose; the barriers to attentive listening; solving the problem of the time attentive listening requires; the importance of the healer’s courage; and attentive listening as one aspect of a healer’s silent receptive mind.

This book relates the author's experience in end-of-life care. It examines the critical values that underlie the doctor–patient relationship and the process of joint decision making, and provides practical guidance for clinicians, patients, and families for conducting critical conversations around several difficult topics. It discusses the difficult clinical and ethical issues faced by clinicians, patients, and families as a routine part of end-of-life care and stresses the importance of committed relationships in palliative care.

One of the more prominent features of modern governance is its increasing reliance on guidelines. Sometimes they acquire such an aura of authority that they are assumed to be part of the general law. This misperception is not uncommon among health-care personnel; it is likely to become more widespread as a result of new arrangements for ‘clinical governance’ in the NHS, as further extended and reinforced by the Health Act 1999. This chapter discusses the limits to implementation of guidelines, the legal status of guidelines, and the impact on medical practice and the doctor-patient relationship.

This chapter discusses the case of Lily Sterns, an elderly patient who, in the spring of 1980, was diagnosed with cancer of the uterus. Lily's case is able to describe the proper care of the suffering patient. It reiterates the importance of the doctor–patient relationship, which is the vehicle through which the relief of suffering is achieved.

The author here elaborates on how a virtue ethics regulatory model might combat medical conflicts of interest. The author explains how, in evaluating a certain regulatory intervention here, such a model could investigate the impact which such an initiative may have had on doctors’ prioritising of patients’ best interests over other considerations in their prescribing decisions, in other, comparable sorts of cases, such as pay-for-performance schemes. The author also indicates how a virtue ethics policy approach in this context could examine what policymakers can do to help professional associations in medicine meet their avowed goals of preserving the therapeutic orientation of doctor-patient relationships, at a time of an increasing commercialization of medical practice. In doing so, The author hopes to show how virtue ethics can play an important role in helping to devise effective and well-targeted regulatory solutions to such problems.

The fifth chapter examines the increasing role, from the 1750s, of literary and medical narratives in inscribing physiological disorders into a coherent progression. In novels by Lennox, Godwin, and Diderot, the body’s manifestations appear as a code, a truth, or a manipulation, depending on the author’s specific narrative demands. They are presented as a language of the body, marking turning points in the progression of feelings, and function as a means to question the relationship between identity and representation. In narratively structured manuscript reports by correspondents of the Société Royale de Médecine and observations published in medical treatises, hysteria is often presented as a fascinating, at times a bewildering, pathology. Toward the end of the century, the observations increasingly become a place to see the pathology as a testament to the patient’s education, way of life, and emotions. Such narrative claims not only to identify the diagnosis, but also to make it intelligible, grounding the diagnosis in the patient’s past emotional and physiological experiences.

Placebo effects operate through the sociocultural beliefs that an injection, or a pill, is a healing agent in itself, independently of its actual constitution. These beliefs are naturally tightly linked to the meaningfulness of our environment; a doctor’s white coat, soothing words, or hospital equipment can all create physiological effects. This chapter explores the meaning that people assign to their doctor–patient relationships—specifically, the psychological difference between trusting a doctor who is perceived to be both competent as well as acting with the patient’s well-being in mind as against trusting a doctor who is perceived to be merely competent. Could this distinction in “trust” make a difference in the context of placebos? The chapter provides evidence supporting this hypothesis and suggests ways to test it. If correct, the hypothesis has implications not only for the theory of placebos but for healing more generally.