Several forces, most of them economic, have converged in the last decade to impede the ability of psychiatrists to achieve a trusting bond with their patients. The roots of this problem lie in changes in the way students and residents are taught about the importance of this relationship.

This negative development should trouble psychiatrists who, more than any other physicians, know the power the relationship has in guiding them to the right diagnosis and the best treatment choices, said Carolyn Robinowitz, M.D., former dean of the medical school at Georgetown University.

Speaking at a symposium at APA’s 2000 annual meeting in Chicago in May, Robinowitz said the foundations of the problem are laid as early as in medical school and residency training. She lamented the fact that providing medical students and residents with the tools they need to build trusting physician-patient relationships is no longer a priority of educators and residency supervisors.

These teachers and trainers convey a message to their students that listening to patients, respecting their idiosyncratic responses to medical care, and building the foundation for a trusting relationship are less-worthy goals than medicating the patients’ symptoms and getting them quickly out of treatment.

Scientific decision making is certainly a critical element of successful treatment, Robinowitz said, but it is not the only one, and "it has to be informed by the best interests of the patient." This means that new physicians, particularly psychiatrists, need to be taught to weigh "a full range of treatment options that may be appropriate for a patient’s illness."

For too long psychiatrists were accused of excluding science and relying on their intuition to decide how to treat a patient, "but in reality much of that intuition can be aided by science," she said.

When scientific advances are the sole foundation of treatment, however, psychiatrists will never achieve the level of trust they need to gain crucial insight into their patients’ problems. And if patients don’t trust their psychiatrist—or any other physician on whom they are counting to help them feel better—that clinician will not be able to get good historical data from the patient or convince that patient of the value of treatment adherence and open communication, Robinowitz emphasized.

It is vital for medical educators to teach students that the doctor-patient relationship is a critical part of good medical care, she said, because the patient’s willingness to communicate openly with his or her physician—and the physician’s willingness to listen attentively—is key to preventing medical errors, treatment-compliance failures, and malpractice suits, she said. One new element in the doctor-patient relationship is the need for physicians to educate themselves about the alternative treatments, including herbal, that more and more patients inquire about, she noted.

Addressing why medical educators and residency trainers are giving these important considerations shorter and shorter shrift, Robinowitz cited in particular the economic factors driving the U.S. health care system. Teaching and patient care time "is getting more and more restricted," she said. Residents claim they don’t have time to teach medical students anymore in light of pressures to see more patients quickly and the hours they have to spend on follow-up paperwork. Trainees also have fewer opportunities to follow hospitalized patients because of insurance restrictions and disincentives to provide comprehensive treatment, she explained.

Also conspiring against teaching the elements and importance of the physician-patient relationship are, paradoxically, practice guidelines and best-practices lists, Robinowitz maintained.

"It seems contradictory," she said, but these usually helpful tools can lead to "one-size-fits-all thinking" in which psychiatrists and others overlook patients’ unique responses to treatment. "Some of our patients have outlier responses" that must be considered when psychiatrists think about the appropriate treatment algorithm, she said. They must find the time to assess how patients—who have not read the same handbooks as their psychiatrist—feel about their treatment and what they are conveying about factors that will affect treatment adherence—that is, "how the treatment fits that patient."

The ability to evaluate these factors depends on the strength of the relationship the psychiatrist and patient have developed, she noted, but this skill is lost when students and residents are taught to focus almost entirely on the effects of medications on patients’ symptoms.

Changes in undergraduate medical education have resulted in an inordinate emphasis on the importance of technology, Robinowitz noted, to the exclusion of teaching about communication skills, which are "more labor intensive." The situation is further aggravated by the reward system of medical schools and teaching hospitals, where recognition, money, and tenure come from research and clinical care, not from teaching future doctors, she said.

The "task-driven" focus of residencies also means that young physicians are missing out on opportunities to learn how elements of good communication affect patient outcomes, Robinowitz stated. Residents rarely get the chance to conduct sufficiently long interviews to understand a patient or to see a patient enough times to allow "emotional threads" to develop. Many programs have "replaced human interaction with computer simulations, but this doesn’t give residents real-life experiences with complex patients," she said; it just reinforces their reliance on technical skills.

The fact that psychiatrists may be on the short end of a power imbalance when it comes to influencing the medical education system does not, she emphasized, relieve them of their obligation to combat influences that are weakening that crucial building block of successful treatment—the physician-patient relationship.—K.H.