The Patient-Doctor Relationship

A patient writes a letter to a doctor. Before the treatment starts, the patient thinks that both should know each other well, as one needs the other for survival. The patient is expecting a few privileges that are due to a sickness. He expects the doctor’s solicitous attention. At the same time, he is willing to surrender himself to any enquiry the doctor imposes on him. The patient thinks he is more than a damaged organ, he is a human being. He is worried, at the same time, hopeful, because he is with the doctor. He trusts his doctor. He has come to him with the understanding that his treatment will depend upon the quality of his relationship with the doctor. The evolution of the doctor-patient relationship is important for him.

Sushruta was a physician in ancient India. Ayurvedic Medicine is one of the oldest medical systems in the world, dating back to the Vedic Period of India. The Sushruta Samhita is an instruction manual for physicians to treat their patients holistically. Disease, following the precepts of Charaka, was caused by imbalance in the body. Sushruta described the ideal medical practitioner thus: That person alone is fit to nurse, or to attend the bedside of a patient, who is cool-headed and pleasant in his demeanor, does not speak ill of anyone, is strong and attentive to the requirements of the sick, and strictly and indefatigably follows the instructions of the physician. To Sushruta, the practice of medicine was a journey of understanding for which a physician required a keen intelligence to recognize what was necessary for good health. In one passage, he writes: The science of medicine is as incomprehensible as the ocean. It cannot be fully described even in hundreds and thousands of verses. Dull people who are incapable of catching the real import of the science of reasoning would fail to acquire a proper insight into the science of medicine if dealt with elaborately in thousands of verses. Sushruta recognized that optimal health could only be achieved through a harmony of the mind and body. This state could be maintained through proper nutrition, exercise, and rational, uplifting thought. In certain cases, however, when the patient's imbalance was severe, surgery was considered the best course. To Sushruta, surgery was the highest good in medicine because it could produce the most positive results more quickly than other methods of treatment. The definition of an ideal surgeon, according to Sushrutaa is, A person who possesses courage and presence of mind, a hand free from perspiration, tremor less grip of sharp and good instruments and who carries his operations to the success and advantage of his patient who has entrusted his life to the surgeon. The surgeon should respect this absolute surrender and treat his patient as his own son.

The practitioners of Ayurveda, known as Vaidyas, thought of each individual as unique. The Vaidyas laid equal emphasis on the cure of disease as well as prevention and health promotion. They advocate harmony of body and mind, and a harmonious interaction between man and universe for a healthy life. The patient is examined as a whole, and not just his disease. Ayurveda sees a much wider role of a physician. He is not merely confined to treating the patient, his role is extended to include an individual reach to achieve his spiritual goals of self-emancipation. The Vaidyas required wisdom and skilled communication. A vaidya is expected to be friendly and sympathetic toward his patients so that they do not fear him. A Vaidya should focus on curing the illness, and refrain from discussing domestic affairs or from announcing the impending death of a patient. Charaka says that the purpose of studying medicine varied for different castes. Brahmins studied medicine out of empathy, Kshatriyas wished to keep people safe, whereas Vaishyas did it for monetary gains. Charaka asserts that it is training, not birth, that makes a vaidya. Practical training was an important part of Ayurvedic studies.

The genesis of the patient-doctor relationship is quite interesting. It evolved in the form of the priest-supplicant relationship in Egypt; the priest assumed the ideology of a parent-figure. Nature played a key role to resolve the matters related to sickness and death by means of magic, mysticism, and theology. Healers were magicians and priests. Magic was an integral part of care. Treatment was largely limited to external and visible disorders, such as fractures. The internal psychiatric disorders presented certain observational difficulties. It was due to the naïve, culturally unsophisticated approaches to medicine. The Greeks developed a system of medicine that was based on naturalistic observation, abandoning magical and religious justifications of human bodily dysfunction. The Hippocratic Oath codified the doctor’s attitude towards his patient and also the rights of the patient. The restoration of religious and supernatural world beliefs, following the demise of the Roman Empire, led to the deterioration, weakening and regression of the doctor-patient relationship throughout medieval Europe. The doctor, filled with magical powers, was in a glorious, high ranking position in society. His patients were regarded as helpless infants. The French Revolution brought in changes in the doctor-patient relationship from an activity-passivity approach to a guidance-cooperation model. This was the time when the doctors were few in number, and their patients mainly upper class and aristocratic. This brought in the supremacy or dominance of the patient. The model of treatment was also based on the interpretation of the patients’ individual symptoms. During the late 18th Century hospitals emerged to treat patients who were underprivileged. With this, began the era of medicine that focused on the accurate diagnosis of a pathological lesion inside the body. This model required the examination of the patient's body, and on the basis of clinical and anatomical knowledge, the doctors formulated diagnosis.

The emergence of psychology necessitated a genuine communicative relationship between a doctor and a patient, and that led to the creation of patient-centred medicine. Doctor was needed to understand the patients’ personality along with the patient's physical signs. In the patient-centred approach ‘therapeutic alliance’ (empathy, congruence and positivity) is necessary between a doctor and a patient. Besides the medicine, the doctor is an integral part of the treatment; his sensitivity, insight and emotional responses are as important as the medicine. The digital intervention in the world of medicine has made a big difference in the way we are treated and will be treated in the future. Its implications are both good and bad. It will make doctor-patient alliance impersonal and remote.

There was a time when prayer was the only medicine. Then plant roots served as medicine. Then concoctions and artificial entities made from natural products came to rescue us. This was followed by the age of pills, and then came the age of antibiotics. It is now the age of gene-therapy and precision medicine. Sickness will continue to be the priority concern of many, but for a large group, wellness will also be equally important. Now more and more people are realising that a disease evolves over time, through the interaction of genetic, environmental and lifestyle factors. The future medicine will follow therapy, based on a patient’s unique genetic and lifestyle profile.