A Review of the Relationship between Patient and Physician from a Historical and Ethical Point of View
Physicians need to have a good relationship with their patients during their careers in order to provide optimal treatment. The Physician should be always on the basis of the principles of medical ethics in order to benefit and provide the best interest to his patients. Considering the cultural and conventional conditions, and the characteristics of patients in Iran, using the old and new internal and external sources, and its adaptation to the native conditions of Iran can first, on the basis of Deontology and then virtue-oriented, establish the best communication in order to better providing the service. In this paper, considering the important issue of the relationship between the patient and the physician and its effect on the treatment process, several important issues raised in this regard and the analysis of the views of the scholars from the historical and ethical point of view has been addressed and by summing up these comments, we are discussing the special position of this relationship so that distinguished physicians are more aware of the importance of advancement in the therapeutic goals and have an effective relationship with the current situation in Iran.
KeywordsPhysician-patient relation, Effective communication, Medical ethics, Health communication
Due to the need of surviving and continue of life, humans try to relieve their pain by resorting to medication and primitive treatment when they do not achieving the result of treatments and being frustrated by using magic. But due to finding ways to restore lost health and well-being is not an easy task , man has always been seeking a therapist, who trusts him/her to relieve his/her suffering to seek his recovery. According to historical evidences, there were often people in the medical profession, who could not establish a well relationship with the patient . In order to prevent this phenomenon, rulers and wise men have imposed laws and regulations in different period of times which one of the most famous in medical writing is the Hippocratic Oath  that emphasizes the moral obligations of the physician towards the patient and the community. Galenus, the prominent physician after Hippocrates, also reminds that the main task of the physician is to maintain the health of healthy people and restore it for those, who have lost it . This idea has been introduced as the beginning of important sources of Islamic civilization such as the Book of Law . After translating into Arabic in the middle of the 3rd century AH, the teachings of Jalin created the foundations for the era of Islamic civilization  which had centuries of credibility until new medical practices replaced, in many cases especially past practices. In this long way, one of the issues that have kept its value and status since Hippocrates hitherto, despite its new developments and changes in the meaning of patient-physician relationship, is the ethics of the relationship between patient and physician that is appreciated by most contemporary medical societies.
This study was an overview with the aim of reviewing valid sources and databases and scientific information sources such as PubMed, Google Scholars, and Scopus to investigate the patient-physician relationship between August and October, 2017. August 2017 and with the keywords “physician patient communication, doctorpatient relation and the physician-patient relationship” were searched for the period of 2010 to date. Also, there are scientific books of domestic and foreign magazines, as well as a collection of historical and scientific aspects related to the above issue that were published in recent years. And according to the subject of the writer's experiences and the names of the distinguished professor Dr. Tabataba'i and other internet resources such as web pages, the article was written.
"DOS AND DON'TS" ABOUT "PATIENT-PHYSICIAN RELATIONSHIP" FROM PAST TO PRESENT READOUT
Resources of old medicine
Borzouyeh, who was the most prominent Iranian physician of pre-Islamic Iran and lived at the end of the Sassanid period, refused to establish a physician's relationship with a patient for purposes other than healing, and he said in part of his speech: "It is imperative for the distinguished physician to take care of the remedy for the preservation of the hereafter in order to provide the fullest of the world with this pleasure, so the salvation of the hereafter would be easier" [1,7]. Muhammad Ibn Zakariya al-Razi in his medical works, especially al-Hawi, al-Mansouri and Mehnat al-Tabib, has raised many points about the relationship between the physician and the patient and expressed various ways to evaluate the clinician in order to avoid establishing a therapeutic relationship with people, who were not qualified. His emphasis on observing moral points in establishing a physician and patient relationship is valuable and noteworthy [2,6,8]. Ali Ibn Abbas Ahwazi, Avicenna, Biruni, Akhavini Bukhari, Soroush Samarghandi, Seyyed Ismail Jorjani and their followers until the end of the thirteenth century AH, in their works, directly and indirectly, emphasized on their characteristics, which they were important for physicians and patients, including the ability of physicians to have sufficient knowledge and skills in physical and psychological assessment, tolerance and kindness, follow-up therapy, familiarity with primary and alternative drugs, and guessing the prognosis for making the right decision [9,10]. It should be noted that the validity and worthiness of the old ethical recommendations on the relationship between physicians and patients is an issue independent of their diagnostic and therapeutic methods, which should not extend the value of this to other subjects of old medicine.
General comments: There are a lot of interesting and valuable points in re-reading the works of some of the contemporary physicians, who have been recognized as professors of universities and founders over the past half century and can be described as a recipe for the relationship between physician and patient. For example:
• The physicians of this land, despite current beliefs, are from the masses of people because they are being grown among them, and they know that separation from people is a breakdown of self. Iran's hardworker physicians, especially those working at university hospitals, continue to work on a day-to-day basis in spite of limited facilities. Because they love their profession, and if they are become physicians, they have no motivation other than serving humans and they can endure circumlocution at the patient's bedside in name of human dignity, perhaps, for hours long, which bureaucrats cannot tolerate a minute of hearing patients word.
• In order for a physician to provide better health benefits for his/her co-workers, he or she must keep up with medical professionals .
• Respect for the values of human being we deal with is recognized as a connection, and the most important feature of the physician is the involvement and deep engagement in others' lives.
• So, if you are out of professional careers, it is considered a matter of privacy and interference in personal life and privacy, but the demand for treatment from the physician is an invitation to be associated with the crises of the patient's life .
• Physical diagnosis is a bridge between disease and illness treatment. Often, these two words are identical and equal, but the difference is significant. In pathology, they study illness and deal with illness education. In pathology, they examine the disease and deal with illness in clinical education. Ideally, the physician will consider both disease and illness. Attention to illness can be dangerous. Considering all the social and psychological factors affecting the patient is undoubtedly useful, but it is not enough on its own .
In connection with the "patient-physician relationship", general and partial jurisprudential rulings have been raised, some of which are referred to as examples.
Any medical action and the cost of medication and treatment for the needy and the poor are well-qualified and the necessary examinations for diagnosis are obligatory and, if negligent, the guarantor would be the physician. It is obligatory to know about new discoveries and to use common medical methods. If diagnosis of a disease would be necessary dependent on performing tests and provide necessary documents of diagnosis techniques (radiographs, CT scans, MRIs), diagnosis of the disease is not allowed on suspicion without doing so. The physician is required to refrain from prescribing the medicine until he has identified the disease. Also, it is not permissible to prescribe any medication or any treatment that is based solely on the patient's insistence .
According to the consensus of the scholars, the practice of the ignorant physicians should be prevented and if a person without scientific competence takes medical action, in terms of reason and custom is guarantor and responsible. Also, the physician is not aware of what he/she has been doing due to his/her treatment. Also, the physician is not aware of the damages being done due to his/her treatment which makes him/her responsible.
Regarding to cardiovascular disease, we refer to a special commentary on "–patient-physician relationship". The problem with angina pectoris does not end with prescription medication or surgical recommendation and instead of treatment management should be done for him.
This means that the patient must be carefully studied and the interaction of the illness be taken into account in his or her lifestyle, the physical and emotional stresses that provide the pain, and even the pleasurable activities that are forbidden by angina should be specified for him [15,16].
RECOMMENDATIONS TO NEUROLOGISTS RELATED TO "PATIENT-PHYSICIAN RELATIONSHIP"
The neurologist should be bored and very carefully evaluated for clinical signs to determine the functioning of the cranial nerves, the motor system, reflexes, sensation, standing and walking, the sphincter and the automated nervous system, the neck and the spinal cord. The reason why several neurologists agree on a diagnosis is that the symptoms of neurological disorder are initially incorrectly interpreted and therefore a physical reexamination of the patient is necessary. Adolescents with epilepsy are emotional and psychologically sentimental unstable, and need exact guidance. Prognosis for epilepsy will be appropriate if they can lead them to a regular life, especially on sleep, and continue treatment on a regular basis [17,18].
A FEW TIPS TO PSYCHIATRISTS IN RELATION TO "PHYSICIAN–PATIENT RELATIONSHIP"
One of the main goals of the interview with the patient is to understand the implications and create a therapeutic relationship with the mutual trust between the physician and the patient, and ultimately intervene to prevent and treat . 25 to 30 percent of outpatients and 40 to 50 percent of inpatients have at least one diagnosed psychiatric disorder, the most common being depression, anxiety and drug abuse . A single cause can have many consequences (maternal deprivation can lead to depression, antisocial personality, suicide, etc.) and, on the other hand, a specific disorder can be caused by several causes for example depression can be due to genetic factors, growth experiences and adult stresses . In emergency situations, focus should be on the current problem, and less attention to full biography, but care should be provided in outpatients in children under the age of puberty.
SOME TIPS AND ADVICE FROM THE BOOK "MEDICAL ETHICS IN THE FIELD OF OBSTETRICS AND GYNECOLOGY"
Relationship should be based on confidence, trust and faithfulness. In the relationship between the physician and patient, all medical judgments must be preserved and welfare of the patients has to be considered, too. A gynecologist should always take the patient's side and use all the logical tools to provide the best interest for the patient. A gynecologist must get informed consent from all patients. The information should be provided with understandable words to the patient and refrain from any unproductive action and do not discriminate between patients. The gynecologist should use advising and organizing if necessary. Sexual immorality of a gynecologist includes abusing professional power and violating the patient's trust. Any sexual relationship between a physician and a patient is always immoral .
TIPS ON "PATIENT-PHYSICIAN RELATIONSHIP" IN A FEW OTHER CASES
Communication and interaction with people who suffer from personality disorders and sexual deviations [19,22], prisoners and those involved in legal matters, dangerous psychological patients for themselves or their relatives, children, adolescents, the elderly, pregnant women, mentally retarded people, and people with mental illness cognitive impairments, ethnic and religious minorities, refugees and asylum seekers, and many others, each requires professional skills and experience. And the lack of experience or neglect of this issue not only prevents the establishment of a proper professional relationship but also can lead to undesirable or even irreparable complications. An explanation in these cases requires a wider scope.
Some Recent Studies
The relationship between the patient and physician is a relationship between a person, who is being treated and another person who knows how to treat. In this regard, each one of the parties consciously influences the other, and this influence can be formed as a virtue-oriented approach to move away suffering in a transcendental path or being in an unfavourable way, with increasing pain and discomfort which leads to disorientation and inaccuracy. Based on the research, effective relationship between the physician and the patient is considered as the first step in the treatment process and it seems that the appropriate link in improving the patient's therapeutic conditions as a prime outcome of healthrelate quality-of-life (HRQL) plays a role in clinical practice every day. It will play an important and effective role in improving the conditions and quality of life of the patient. If this relationship is not established, the likelihood of the treatment and satisfaction of the patient will significantly decrease [23,24]. In some new studies based on the concept of "patient-centric", they provide a functional definition for patient-centred communication, which includes three components:
• Discover and understand the patient's perspective (concerns, ideas, expectations, needs, feelings, and performance).
• Understanding the patient in terms of psychological and cultural background.
• Achieving a common understanding of patient problems and treatments that are in line with their values and the patient must receive adequate information about the disease and its mode of action through the physician and the physician will explain the patient-related illness to the patient and taking on treatment management of the patient [25-27].
Other studies have shown that patients are eagerly embraced by a patient-centred approach, and they tend to express the problem in plain language, to understand their concern about the problem and the impact that they have on the family and the surrounding people, and to their financial ability to pay attention to management decisions that are appropriate to the nature of the problem, priorities, and therapeutic goals . In this regard, it has been said that the relationship between the physician and patient can differ depending on the patient's social class and patients have different communication styles based on their social class and intellectual and cultural level. For example, patients with a higher social class than those who are lower in the category are willing to ask for and receive more explanations and patients who are lower in social classes often suffer from more and more chronic problems and often have a lower level of education and ability to understand health-related information and feel more likely that some unexpected incidents and illness are beyond their control. The study found that communication and perception of doctors could be related to patient demographic characteristics (education, income, occupation) . In another study, the communication style has linked physicians to patient satisfaction with health care. The patient's assessment of the physician's relationship is strongly correlated with the patient's assessment of health care services, which indicates that the suitability of the appropriate relationship between the physician and the patient can be related to the suitability and physicians' characteristics in providing appropriate health care services. The seriousness of the disease, the age of the physician, the physician's specialty and the number of previous visits affect the importance of the relationship between the physician and the patient and in the assessment of health care .
Effective behaviour in determining patient satisfaction seems to be of the highest importance.
Effective behaviour and effective manner can have the greatest effect on improving relationship. Studies have shown that 70%-60% of diagnosis of diseases and medical decisions are based on the information obtained from the exact interview due to the proper relationship between the physician and patient . Based on studies published till now), different results were obtained from 106 related studies and 21 experimental interventions that focused on the role of physicians and patients in increasing the level of patient adherence to treatment as one of the major goals of this relationship. Good communication in the health care system is strongly linked to better patient compliance and training physicians for better communication improves patient adherence to treatment. Physical relationship of physician is very positive with the patient's adherence to treatment. The essential elements of the relationship between the physician and the patient include verbal and non-verbal communication, effective questioning and information transfer (behaviour with duty orientation), the use of empathy and worries (social psychosocial behaviour), and participation and collaboration in decision making. The effective relationship between the physician and the patient is empirically related to the outcomes of care, including patient satisfaction, health status, recall of information, and commitment to treatment. The relationship between physician and patient can strengthen adherence to treatment through several mechanisms. The relationship makes the patient aware of the illness and the risks and benefits of the treatment. Supporting, empathy and understanding, participation, and patient-centred interviewing require effective communication and adherence . DiMatteo et al. showed that patients, who are satisfied with their treatment of the physician's attention and interest, and their good relationship, continue to visiting, in contrast to those, who are dissatisfied with the relationship. In the study of Kerse et al. this argument also has been confirmed [32,33].
When a person finds self-reflexivity in himself and others, it evaluates the extent to which strengths and weaknesses can be and the more strengths are, the greater the physician's effect, and vice versa. Me as a physician must know that I am as influential as I am, but in many places I have to be in a state of influence. It has always been a question of whether they write books from patient or patient from books! It is a fact that the patient is the author of the book and our resources, especially at this time, are the same patients and in spite of all non- Iranian sources, who have considered standards for communication with patients based on the common cultures in these areas for many years, there have been and will be the main sources.
Given that our patients as internal resources have properties that are not found in any external source, so using Iranian and Islamic culture, these items will be combined with those items in order to maximize practical and applied comprehensiveness in accordance with the conditions of Iran and practitioners will be able to communicate in a broad and special way that will result in the improvement of the quality of treatment. With the internal vision of ethical issues, they should be placed in a hospital setting and they should be a part of the physician's framework. Our expectations of this relationship should be reasonable in the light of the conditions of the Iran, the community culture and economic conditions. So, we see that sometimes our physicians may be in a society that cannot fully meet the standards of the book and numerous articles and even Iranian-Islamic culture regarding the relationship between the physician and the other, but it is expected to have a sensible relationship to the original core. Because without this basic duty of relationship that leads to the diagnosis and treatment of which the main purpose of the duties of the medical community is not to be realized. Obviously, the main purpose of the referral of the patient to the physician is to restore or provide health and, in some cases, has several stages and since the physician's relationship with the patient helps to achieve this goal, the quality of that attention should be deepened because both of them succeed in achieving that goal directly depends on the quality of this relationship . In order to reach this quality, the physician must be at the highest standard and in line with the conditions of the social and cultural conditions of that society under his control and far from the inescapable and inappropriate expectations of Iran.
As Imam Ali (AS) says to the Shiites "you can be my follower but you cannot be like me".
What is important morally and with respect to this issue is that, in accordance with the new principles of medical ethics, we must first begin with "deontology". Then, look at "virtue-oriented", that is, in the relationship between the physician and the patient, the physician first, without looking at virtue-oriented, firstly looks at the deontology. Then, if it works well, it can, by looking at virtueoriented, take steps beyond the task of advancing the therapeutic approach, and in the first instance, we need to examine the capacities in ourselves and patients. Patient has strengths and weaknesses and selfassessment based on how we communicate with patients. With this self-assessment, you can determine the type of professional activity that involves specific mental and physical conditions. For example, a physician that is more active and effective can be successful in communication and performance in emergency medicine as a general practitioner or an emergency medicine specialist. Due to working conditions and job status, how to deal with patients, are managing different situations with ethical teachings and exercising and managing appropriate relationships with these patients, including trauma with poisoning, suicide and internal disease. A patient and a kind physician or psychiatrist as a general practitioner of admission to psychiatric hospitals or a psychiatrist clinic can work well and appropriate treatment and relationship with different patients from depression to and psychosocial disorder like Schizophrenia, which sometimes have insight and awareness about their illness. During the internship or self-experienced, physicians can acquire this capability and, applying the medical ethics practitioners, will take important ethical steps in relation to the physician and the patient, and develop their self-evaluation of capacity, so that they can take the right decisions in the future in use it in their career. On the other hand, the physician can look at the deontology in a relationship with the patient with the courage to introduce him to another physician in the absence of complete knowledge or expertise related to the type of illness and in this regard, even if we do not coordinate with the physician, we have done at least the task, and also try to overcome our deficiencies.
Appropriate and reasonable professional communication with outpatient or inpatients, short term or long-term, at a private or public health centre is considered one of the most important skills for physicians and this skill of effective communication is considered as one of the qualifications of medical personnel.
Verbal and non-verbal communication, effective questioning using sympathetic phrases and showing the patient's concern are the main elements of this relationship. If such a relationship is made in a desirable and rational manner, it can strengthen and guarantee the patient's adherence to the physician in order to better and more precisely implement the therapeutic orders, which is one of the most important goals of medical systems throughout history.
Considering the necessity of adhering to the four basic principles of medical ethics and observing the "core service, social desirability of the occupation and the fruitfulness", which are considered as components of the medical profession, the referrals to the health centres, in addition to being directly or indirectly, expecting to receive their relationship with the physician and health services within the framework of autonomy, profitability, lack of harm and justice, they have more expectations, depending on several factors. These expectations are subject to patient status, culture, social class, type of office or hospital (public, private, general, specialized), illness (internal, surgical, children, elderly, psychiatric, emergency, etc.) and many other factors, which need to be taken in to account. Given the general and uniform pattern for ethics at the hospitals, a desirable and acceptable outcome for the service provider and recipient especially in Iran, in addition to observing the ethical principles, the importance of religious and ideological culture is also the main expectation of patients.
Conflict of Interest
The authors declare that there is no conflict of interest regarding the publication of this manuscript.
- Sarmadi MT, Zanjani SK. A research on the history of world medicine and treatment: Up to the present era. Sarmadi Publication, Tehran 1999; 1378.
- Khounsari A, Gorji K, Abd EF, et al. Study of international approaches on treatment of common diseases using different methods of complementary medicine. SJIMU 2009; 16: 37-47.
- Larijani B, Zahedi F. Contemporary medical ethics: An overview from Iran. Dev World Bioeth 2008; 8:192-6.
- Langermann YT. Ibn Kammūna and the ‘‘new wisdom” of the thirteenth century. Arab Sci Philos 2005; 15:277-327.
- Martin RC. Enciclopedia of Islam and the Muslim world. Macmillan Ref USA 2004.
- Corbin H. History of Islamic philosophy. Routledge 2014.
- Cowen JS. Kalila wa Dimna. Oxford University Press 1989.
- Mollazadeh H, Emami SA, Hosseinzadeh H. Razi’s Al-Hawi and saffron (Crocus sativus): A review. Iran J Basic Med Sci 2015; 18:1153.
- Biruni AR. The chronology of ancient nations. Sachau, London 1879.
- Hassanzadeh-Ghassabeh G, Devoogdt N, De Pauw P, et al. Nanobodies and their potential applications. Nanomedicine 2013; 8:1013-26.
- Winberg J, Andersen HJ, Bergström T, et al. Epidemiology of symptomatic urinary tract infection in childhood. Acta Paediatr 1974; 63:1-20.
- Chandler JA. Legally-coerced consent to treatment in the criminal justice system. Power and the psychiatric apparatus: Repression, transformation and assistance. Routledge 2014;199-216.
- Olson EJ, Mullon JJ. Clinical diagnosis and basic evaluation. In Textbook of lung cancer, second edition. CRC Press 2008 ; 90-111.
- Nagarani D, Karthik A, Ravi G. A machine learning approach for classifying medical sentences into different classes. IOSR J Comput Eng 2015; 7:19-24.
- Ghasemzadeh N, Salehi SM, Faramarzi-Razini F. Breast milk as the forgotten ethical right in surrogacy and suggestions for its recognition: Islamic perspective, Iranian experience. Iran J Pediatr 2017; 27.
- Baghaei P, Tabarsi P, Farnia P, et al. Pulmonary disease caused by Mycobacterium simiae in Iran’s national referral center for tuberculosis. J Infect Dev Ctries 2011; 6:23-8.
- Danesh J, Wheeler JG, Hirschfield GM, et al. C-reactive protein and other circulating markers of inflammation in the prediction of coronary heart disease. N Engl J Med 2004; 350:1387-97.
- Sanchez-Barcelo EJ, Rueda N, Mediavilla MD, et al. Clinical uses of melatonin in neurological diseases and mental and behavioural disorders. Curr Med Chem 2017; 24:3851-78.
- Goldberg D, Mary R. Mawdesley practical psychiatric guide. Australian Psychol 2004; 27:78-82.
- Ghale-Bandi MF. Clinical psychiatry for students medical and general practitioners. RJMS 2001; 15:31-8
- Sultani AM. Medical ethics in women and midwifery. Legal Publishing, Tehran, Iran 2011; 40-19.
- Kaplan H, Saduk V, Saduk B. Summary of psychiatry of behavioral sciences. Clin Psych 2008.
- Emanuel EJ, Dubler NN. Preserving the physician-patient relationship in the era of managed care. JAMA 1995; 273:323-9.
- Detmar SB, Muller MJ, Schornagel JH, et al. Health-related quality-of-life assessments and patient-physician communication: A randomized controlled trial. JAMA 2002; 288:3027-34.
- Zill JM, Christalle E, Müller E, et al. Measurement of physician-patient communication-A systematic review. PLoS One 2014; 9:e112637.
- King A, Hoppe RB. “Best practice” for patient-centered communication: A narrative review. J Grad Med Educ 2013; 5:385-93.
- Naughton CA. Patient-centered communication. Pharmacy 2018; 6:18.
- Verlinde E, De Laender N, De Maesschalck S, et al. The social gradient in doctor-patient communication. Int J Equity Health 2012; 11:12.
- Buller MK, Buller DB. Physicians' communication style and patient satisfaction. J Health Soc Behav 1987; 375-88.
- Saleheen D, Alexander M, Rasheed A, et al. Association of the 9p21. 3 locus with risk of first-ever myocardial infarction in Pakistanis: Case-control study in South Asia and updated meta-analysis of Europeans. Arterioscler Thromb Vasc Biol 2010; 30:1467-73.
- Zolnierek KB, DiMatteo MR. Physician communication and patient adherence to treatment: A meta-analysis. Medical Care 2009; 47:826.
- DiMatteo MR. Variations in patients' adherence to medical recommendations: A quantitative review of 50 years of research. Medical Care 2004; 200-9.
- Kerse N, Buetow S, Mainous AG, et al. Physician-patient relationship and medication compliance: A primary care investigation. Ann Fam Med 2004; 2:455-61.
2Faculty Member of Medical Ethics Center, Tehran University of Medical Sciences, Tehran, Iran
Citation: Mohammad Nader Sharifi, Seyed Mahmoud Tabatabaei, A review of the relationship between patient and physician from a historical and ethical point of view, J Res Med Dent Sci, 2019, 7(1): 102-107.
Received Date: Dec 05, 2018 / Accepted Date: Jan 08, 2019 /