Conventional Objective Approach

Physicians are trained in the superiority of objective diagnosis and the use of physical agents for treatment effect. Historically, they are also trained to maintain maximum objectivity in patient encounters to ensure that cold, hard reason prevails in synthesizing symptom and event facts, physical examination findings, and laboratory and imaging tests. Prescribed treatment then takes the form of chemical agents, invasive procedures, or surgical intervention. While these bedrock methods have contributed greatly to the improvement of individual and public health, their success is predicated on the patient's acceptance of the diagnosis and treatment, and their adherence to the physician's recommendations. Furthermore, patients seeking medical care may not have a condition with a primary physical etiology, nor may they have the need for a primary physical treatment, nor do physical agents work best without the patient's optimization through belief and behavior.

Communication Study

To explore the importance of the subjective in the effectiveness of medical practice I interviewed 60 of the highest-performing physicians on each of four Regions' (Northern and Southern California, Hawaii, and the Northwest) near-equivalent "Art of Medicine" patient satisfaction survey of physicians' communication and relationship behaviors. Of these, 20 were primary care physicians who participated in a Garfield Memorial National Research Fund naturalistic and observational study on "MD-Patient Communication," for which there also is patient-stimulated recall while viewing the videotape of their live visit with their physician. Using a qualitative research approach of posing a standard set of six questions to each physician in a confidential, face-to-face interview, practice beliefs and behaviors were explored. These recorded and transcribed narratives were then coded for commonality and patterns. One of the questions was: "Do you believe, in the setting of a visit, that you, as a doctor, can create a therapeutic moment for your patient? In other words, that what you say, or how you say it, or your connection with your patient, has a treatment effect?" In conventional medicine, for doctors prescribing drugs for their patients' medical conditions, a therapeutic moment occurs when the drug is ingested and reaches a therapeutic blood level.

Principal Findings

All of the highest-performing physicians agreed that they create a therapeutic moment for the patient (during the visit) to which they ascribe a treatment effect. The physicians believe the necessary context is relationship, and describe one or more of several empathetic activities that produce this moment, including: attention and presence, listening, connection, reassurance and support, explanation, understanding, insight, confidence, certainty, reciprocity, and a feeling of well-being. Physicians believe these activities or states are "part of the medicine" required to heal a patient's illness and treat their medical condition. Physicians describe patient interactions of this nature as responsible for the physician's sense of being valued, making an important contribution, and creating personal and professional well-being.

Implications for Policy, Delivery, or Practice

Relationship, short and long-term, is the necessary foundation, and it brings well-being for both patients and physicians. Highest-performing physicians note the benefit of communication education in improving their satisfying interactions with patients. Medical education, the format of the office visit, and leadership expectations must optimize and emphasize the essential value of subjective empathetic activities and states in creating the highest patient satisfaction and the most effective medical treatment outcomes.