Published on 28 June 2024

When Doctors and Patients turn against each other

Professor Joseph Sung
Dean, Lee Kong Chian School of Medicine

Recently, I come across a case of shattered doctor-patient relationship. A middle-aged patient with metastatic cancer became terminally ill in hospital receiving hospice care. He was deeply jaundiced and showed ascites and signs of multi-organ failure. After the oncology team’s discussion with the family, it was agreed that if the patient’s condition further deteriorated, there should be no resuscitation to avoid prolonged suffering. Two weeks later, at 2am, patient started to drop in blood pressure. There were also signs of bleeding at the rectum, and patient’s consciousness gradually deteriorated. This is evidence of internal bleeding, probably as a result of disseminated intravascular coagulation (DIC) as an end-stage. The on-call doctor noted that the clinical decision was not to perform active resuscitation. Intravenous fluid was given together with Transamine (a drug that is supposed to reduce bleeding diathesis). However, the patient’s condition continued to go downhill and the family was getting emotional. They asked for blood transfusion and more active treatment to stop the internal bleeding. In the midst of heated arguments and rising temperature around the sick bed, a surgeon was called in. Still, the medical team failed to identify the source of bleeding. Eventually, despite the team’s best efforts, the patient succumbed to terminal cancer and uncontrolled bleeding. A proper investigation was called for the case, and it was announced as a Coroner’s case with the body sent for postmortem. This decision further agitated the family who then shouted, “Hospital mismanagement killed our loved one!” and they called the police.

This is a sad situation in which doctor-patient rapport was entirely broken and both sides turned against each other. As the case is under review, I will not comment on clinical management. But questions could be raised on whether more empathy and sensitivity could be shown in this case? In fact, many complaints and even litigations against doctors, nurses and hospital management may stem from this. It happens almost every day.

Doctor-patient relationship describes the interaction of the patient with the medical care provider in a professional setting with the intent of improving patient care. It is built on two basic principles. First, mutual trust and knowledge: the patient’s faith in the doctor’s competence, the doctor’s knowledge of medicine, the patient’s hopes, beliefs, and trust in the patient’s accurate reporting of symptoms. Second, physician empathy: understanding the patient’s experiences, concerns, outlook etc., and being able to express these to the patient compassionately; and loyalty: the patient to the physician and the doctor’s commitment to the patient never to abandon or disregard his or her wishes.

As doctors, we must act ethically, present a professional demeanour, maintain confidentiality while appropriately informing patients about their condition, provide optimal care and guide them towards informed consent for therapies. Healthcare providers have to be a good communicator, upon listening to the patients’ concerns and responding to their needs. A strong doctor-patient relationship can improve many aspects of patient care. Symptom recovery has been shown to depend on the physician’s knowledge of the patient’s ailments and emotional state. A patient who is satisfied with his or her physician is more likely to keep appointments and comply with medicine prescriptions and treatment regimens. Medical errors, patient complaints, and negligence claims could be reduced

Jeanette Bauchat, an expert in patient communication from Vanderbilt University, pointed out that empathy forms the cornerstone of person-centred care. This value is necessary for forming a strong doctor-patient partnership and fosters effective communication that is instrumental to person-centred care. Empathy is also important as it engenders compassion, which can be characterised as “feelings of warmth, concern and care for the other, as well as a strong motivation to improve the other’s wellbeing”. Empathy is a skilled response, whereas compassion is a reactive response. Therefore, empathy is helpful insofar as it acts as a precursor for compassion which allows doctors to act in their patients’ best interest. Yet, nowadays, time is often insufficient for doctors to develop the type of empathetic and compassionate relationship with their patients that is necessary to person-centred care.

Artificial intelligence (AI) is commonly cited as a potential solution to the problems faced by healthcare today, including addressing the dissatisfaction surrounding the nature of the doctor-patient relationship. AI, arguably, has the potential to “give the gift of time” and could, therefore, allow the doctor and the patient to enter more meaningful discussions with respect to care. Is that necessarily true? Sceptics have argued that AI may further dehumanise the practice of medicine. AI tools which lack value plurality may encourage a way back to “paternalism”, when doctors and nurses take up the role of parents talking down to their patients as their children. Take for example IBM Watson’s promise as the first AI tool to help oncologists manage various types of cancer in a multi-dimensional discipline. The machine’s role was designed to rank treatment options based on outcome statistics presented in terms of ‘disease-free survival’ and to show a synthesis of the published evidence relevant to the clinical situation. However, this ranking has not put into consideration the patient and their family’s autonomy driven by individual patient preferences. In this day and age when AI is impacting every level of clinical medicine, the role of human empathy in doctor-patient relationships can and should never be over-emphasised.