The physician-patient relationship defines psychiatric practice, and its primacy distinguishes psychiatry from the rest of medicine. "We not only practice it, we study it and relish it," said psychiatrist Kenneth Silk, M.D. Thus, it is disturbing that the impact of this crucial relationship is waning under the pressures of 15-minute medication-management visits, he pointed out.

Whether these pressures to redefine psychiatric treatment as a series of pharmacological decisions arise from positive or negative sources, the consequence is that psychiatrists are spending less time probing the problems that underlie their patients’ symptoms, maintained Silk, an associate professor of psychiatry at the University of Michigan.

Silk spoke at last month’s annual meeting in Chicago at a symposium led by outgoing APA President Allan Tasman, M.D., on the theme he had selected for the annual meeting, "The Doctor-Patient Relationship."

Silk cited the managed care industry, the increased number of nonphysicians conducting psychotherapy, advances in molecular biology and genetics, safer drugs, and the "cost-benefit ratio" of relying on medications to treat mental illness as the factors impelling psychiatrists toward shorter and shorter patient visits and a weakened relationship with those patients.

Providing patients with optimal care, which hinges on building a strong psychiatrist-patient relationship, now requires that psychiatrists demand from insurers sufficient time to treat all their patients and, if it is not granted, "we must take it," Silk emphasized.

It is imperative to go beyond establishing a treatment goal that centers around "correcting a chemical imbalance," he advised psychiatrists attending the symposium. Chemical imbalance is an "overused term that limits patients and their potential to affect the course of their illness," he said. "It ignores the role of stressors and patients’ reaction to those stressors." It also promulgates the notion that nothing patients do for themselves will make them feel better, he noted. "It is only part of the picture."

He offered his colleagues some valuable advice on how to begin establishing a solid physician-patient relationship during the patient’s initial visit when his or her treatment is likely to involve medication and a limited number of sessions.

Make sure that new patients understand that you want to know information about them that goes well beyond their presenting symptoms, Silk said. This involves scheduling sufficient time to do more than just make a diagnosis; there must be time to delve into underlying issues, especially since future visits are usually only 15 or 20 minutes.

Also, he advised, "reinforce the idea that the patient is an individual with individual responsitivity" to medications’ side effects and effectiveness. The way people think cognitively and express themselves can’t be separated from their presenting symptoms.

The medication-prescribing process is another critical opportunity for psychiatrists to build a strong relationship with their patients. Let patients know, Silk urged, that they can discuss concerns about and side effects of their prescribed medications between appointments.

"I would rather have them call me than just stop taking their medication" if they are troubled by it, he said. Anticipating his listeners’ qualms about the phone-call invitation, he pointed out that he "is not inundated with phone calls. Most people are respectful of physicians’ time. If they view it as an invitation to collaborate, they will call you when it’s necessary."

Elaborating on how medication discussions can help build relationships with patients, Silk suggested that if patients are miserable on their medication, inform them that people react differently to medications and that there are other ones that you can prescribe, and then clarify "what is realistic and unrealistic" to expect from these drugs. It is crucial to use complaints or praise about medications as a cue to ask the patient how the drug is impacting his or her life, Silk said. It is an excellent vehicle for learning information about other aspects of the patient’s life.

Remember, he cautioned, if patients fail to take their medications, there is no way they can do them any good. He suggested, however, that the newer generations of psychoactive drugs, which produce fewer side effects, may reduce the opportunities to use medication discussions as a way to strengthen the relationship psychiatrists need to build with their patients.

Particularly important, he pointed out, is "whenever possible to use the pronoun ‘we’ rather than ‘I’" to foster the idea that psychiatrist and patient are in a collaborative process. The patient’s realization that psychiatric treatment is a collaboration can become "a model for respectful interpersonal relationships" that they can apply to other facets of their life.

Even without the benefit of long-term psychotherapy as part of treatment, psychiatrists can enhance the physician-patient relationship by using every interaction with their patients as an opportunity to "provide psychoeducation and dispel myths," he explained. Psychiatrists build relationships when they are "straightforward about what [they] believe and how [they] practice."