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The evolution of the doctor-patientrelationship

Article in International Journal of Surgery (London, England) · March 2007

Impact Factor: 1.53 · DOI: 10.1016/j.ijsu.2006.01.005 · Source: PubMed

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Prasanna Sooriakumaran

University of Oxford

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On considering a relationship that is based onmutual participation of two individuals, the term‘‘relationship’’ refers to neither structure nor function but rather an abstraction encompassingthe activities of two interacting systems or per-sons.4 The apparent, intrinsic quality of thisunique doctor-patient relationship allows two peo-

ple, previously unknown to each other, to feel atease with variable degree of intimacy. This rela-tionship, in time, may develop to allow the patientto convey highly personal and private matters ina safe and constructive environment.

History of the doctor-patientrelationship

The doctor-patient relationship in a historical settingis dependent on the medical situation and the socialscene. The doctor’s and patient’s ability for self-

reflectionand communication as well as anytechnicalskills are embodied within this ‘medical situation’.The ‘social scene’ refers to the socio-political andintellectual-scientific climate at the time.

The work performed by Szasz and Hollender (1956)5 demarcated three basic models of thedoctor-patient relationship. These are (a) active-passivity, (b) guidance-co-operation and (c) mutualparticipation. The activity-passivity and guidance-co-operation models are entirely paternalistic andthus predominantly doctor-centred. The latter,mutual participation has a greater emphasis on

patient centred medicine. By employing theseconceptual models one can present an historicaloverview of the certain changes that occurredbetween the doctor and patient which led to thedevelopment and creation of a patient-centredfocus that is currently practised today. The socialconditions and medical practice models of thefollowing periods will be briefly discussed:

(a) Ancient Egypt (approximately 4000 to 1000 B.C)(b) Greek enlightenment (approximately 600 to

100 B.C)(c) Medieval Europe and the inquisition (approxi-

mately 1200 to 1600 A.D)(d) The French revolution (late 18th century)(e) Doctor-patient relationship 1700-to present day

Ancient Egypt

Edelstein et al. (1937)6 proposed that the doctor-patient relationship evolved from the priest-suppli-cant relationship, thus retaining the ideology ofa parent-figure to manipulate events on behalf ofthe patient. Man has attempted to master nature,

through his fears of helplessness, sickness anddeath, by means of magic and mysticism, theologyand rationality. Healers were as much magiciansand priests as they were doctors and magic was anintegral part of care. Treatment was largely limitedto external and visible disorders such as fractures.Psychiatric disorders which were regarded as inter-

nal, presented certain observational difficulties inthe face of a na€ıve, culturally unsophisticated ap-proach to medicine. It therefore seems likely thatin ancient Egyptian medicine the activity-passivitytype relationship existed and that this relationshipwas unaltered. Neither the social circumstancesnor the technical advances were such as to requirea change within this relationship.

Greek enlightenment (5th Century B.C.)

The Greeks developed a system of medicine basedon an empirico-rational approach, such that they

relied ever more on naturalistic observation, en-hanced by practical trial and error experience,abandoning magical and religious justifications ofhuman bodily dysfunction. They were also amongthe first nations to evolve towards a democraticform of social organization, and consequentlyestablished equality among the electorate. Thusguidance-co-operation and to a lesser degreemutual-participation were the distinguishingpatterns of the doctor-patient relationship.

The Hippocratic Oath established a code ofethics for the doctor, whilst also providing a ‘Bill

of Rights’ for the patient. The rules codifying thedoctor’s prescribed attitude towards his patient7:‘‘The regimen I adopt shall be for the benefit of

my patients according to my ability and judgment,

and not for their hurt or for wrong .Whatsoever

house I enter, there will I go for the benefit of

the sick, refraining from all wrongdoing or corrup-

tion, and especially from any seduction, of male or

female, of bond free. Whatsoever things I see or

hear concerning the life of men, in my attendance

on the sick or even apart there from, which ought

not be noised abroad, I will keep silence thereon,

counting such things to be as sacred secrets.’’

This oath provides a higher degree of humanismin dealing with the needs, well-being, and in-terests of people when compared to previouscodes of conduct. In this, the Hippocratic Oathraised medical ethics above the self-interests ofclass and status.

Medieval Europe and the inquisition

The restoration of religious and supernatural worldbeliefs, following the demise of the Roman Empire,

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and concluding in the Crusades and witch-huntsthroughout the middle-ages, led to the deteriora-tion, weakening and regression of the doctor-patient relationship throughout medieval Europe.The, magico-religious beliefs personified in the Oldand New Testaments were revived and becamewidely accepted. The doctor, filled with magical

powers, was in a glorious, high ranking position insociety and his patients were regarded as helplessinfants, analogous to the activity-passivity model.

The French revolution

Through the initiation of the Renaissance encour-aged by the emerging Protestantism, Man’s searchfor liberalism, equality, dignity and empirical sci-ence began once again. There are marked illustra-tions of the effects of the dominant socio-politicalevents (e.g. the successful Protestant protestsagainst the unimpeded might of the Roman Catholic

Church, the removal of English dominance fromAmerica, and the momentous social struggle of theFrench revolution) on medical attitudes, actionsand thus behaviours during this time. The eventsthat led to the French Revolution brought an end toan era in which the mentally ill and socially un-derprivileged were incarcerated in dungeons.5 Thisexemplifies the change in the doctor-patient rela-tionship from an activity-passivity approach toa guidance-co-operation model.

Doctor-patient relationship from 1700 to

present day

‘‘The relationship between the doctor and patient

has a very pronounced association with the model

of illness that dominates at any given time’’.8 Dur-ing the 18th Century the symptom was the illness.Doctors were few in number and their patientsmainly upper class and aristocratic. This status dis-parity ensured the supremacy or dominance of thepatient and doctors had to compete with eachother in order to please the patient. The modelof illness that developed was one based on the in-terpretation of the patients’ individual symptoms.The doctor found that it was less necessary to ex-amine the patient but rather more important to beattentive to their needs and experiences manifestin the form of their symptoms. This symptom-based model of illness ensured the preservationof patient dominance throughout this period.

During the late 18th Century hospitals emergedas places to treat patients who were underprivi-leged. Doctors now found themselves providingmedical treatment for those who were traditionallyregarded as more passive. The hospital became the

cornerstone of medical care and along with therapid growth in microbiological knowledge andsurgical skills during this time, a new Medicinedeveloped that focused not on the symptom, butrather on the accurate diagnosis of a pathologicallesion inside the body e the biomedical model ofillness. This new theory suggested that the symp-

tom was no longer the illness, but instead acted asa unique indicator for the presence of absence ofa particular pathology. This new model required theexamination of the patient’s body and the expertclinical and anatomical knowledge possessed by thedoctor to formulate a diagnosis, and thus the patientbecame dependent as a result. The relationshipwas between a dominant doctor and a passivepatient, i.e. an activity-passivity (paternalistic)model.

The development of paternalism

The Hippocratic doctors considered it an ethicalrequirement to follow the ‘criterion of benefi-cence’ as well as the principle ‘primun non nocere’(‘not to hurt’) which has become a core principleof medical ethics within the doctor-patient rela-tionship. Hellin (2002)3 regards paternalism ashard-line beneficence, analogous to the parent-infant relationship5 in which the infant is whollydependent on the parent for decision-making.Thus the doctor’s role involved acting in thepatient’s best medical interests,1 with doctorsregarding a ‘good patient’ as one who submissively

accepted the passive role of the infant.3

The emergence of psychology

The psychoanalytical and psychosocial theories pro-posed by Breuer and Freud (1955)9 in the late 19thCentury began to further constitute the patient asa person. This therapeutic model meant that, interms of the doctor-patient relationship, it was ofgreat importance to listen to the patient at greatlength. Their interest in the patient allowed themto develop a genuine communicative relationshipand reintroduced the patient into the medical con-sultation as an active participant. This early thera-peutic intervention paved the way towards thebroad implementation of mutual participation be-tween the doctor and patient5,10 which ultimatelyled to the creation of patient-centred medicine.

The doctor had become conscious or aware ofthe patients’ personality: ‘‘the patient was notsimply an object but a per son, needing enlighten-

ment and reassurance’’.11 The report of the Plan-ning Committee of the Royal College of Physicianson Medical Education regarded as essential that

The evolution of the doctor-patient relationship 59

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‘‘from the beginning of his clinical career, the stu-

dent should be encouraged to study his patient’s

personality . just as he studies his patient’s phys-

ical sig ns and the data on the temperature

chart’’.12

The theories of Balint (1964)10

Michael Balint trained in both medicine and psycho-analysis, and attempted to combine these sciences.He acknowledged that an individual’s tendency toseek the attention of a GP could not be described insolely objective terms; social and psychologicalinfluences were equally important. He argued thatillness was as much a psychosocial phenomenon asa biological one. He encouraged doctors to look pastthe physical signs and symptoms reported and tofocus on the patient’s unique psychological andsocial context, thereby allowing them to under-stand the ‘real’ reason for the consultation. He alsoproposed that the unique emotional relationshipthat develops between the doctor and patient over many encounters is itself a critical constituent ofboth therapeutic and diagnostic processes.

Balint’s concept of the ‘‘doctor as drug’’ em-phasised the dynamic nature of the doctor-patientrelationship. He adamantly maintained that ‘‘themost powerful therapeutic tool the doctor pos-

sessed was himself or herself’’. However, Balintacknowledged that very little was known aboutthe ‘pharmacological’ aspects of this drug, suchas the correct ‘dosages’ (frequency of visits), any

addictive properties (whereby the patient be-comes increasingly reliant on the doctor), andside effects (i.e. what harm the doctor coulddo). Another concept of the doctor-patient rela-tionship that Balint described was what he coined‘‘mutual investment’’. He believed that the indi-vidual consultation was one in a series of consulta-tions, as opposed to a single episode, such thateach consultation followed on from the next.With time the doctor obtained the patient’s trustand or confidence, such that he began to knowmore and more about his patient’s personalities,social and physical environments, their biographyand their relationships. This allowed the doctor to improve his time management skills, so thateach new consultation was more effective, whichultimately provided a better insight into the pa-tients’ needs. The ideology behind mutual invest-ment also incorporates the opportunity for thepatient to develop insight into the doctors ownneeds. This implied that the doctor-patient rela-tionship was a mutual investment which over time would benefit both parties.

The three basic models proposed by Szaszand Hollender (1956)5

Szasz and Hollender (1956)5 proposed three modelsof the doctor-patient relationship (alsosee Table 1):

(a) The model of activity-passivity is entirely pa-

ternalistic in nature; this is analogous to theparent-infant relationship described previ-ously. They argued that this model is not an in-teraction, as the person being acted upon isunable to actively contribute. The patientis regarded as helpless requiring the expertknowledge of the doctor, and treatment iscommenced ‘‘irrespective of the patient’scontribution and regardless of the outcome’’.This is entirely justified in the medical emer-gency setting because the time required toget informed consent or involve the patient indecision making would clearly jeopardize thepatient’s health. This type of relationship pla-ces the doctor in total control of the situationand ‘‘in this way it gratifies needs for master y

and contributes to feelings of superiority’’.13

(b) The model of guidance-co-operation is em-ployed in situations which are less acute. Theyargued that despite the fact that the patient isill, they are conscious and thus have feelingsand aspirations of their own. During this timethe patient may suffer from anxiety and painand in light of this he may seek help. The patientis, therefore, ready and willing to ‘‘cooperate’’

and in doing so he places the doctor in a positionof power. Therefore the doctor will speak ofguidance and thus expect the patient to cooper-ate and obey without question. They describedthis model as a prototype in the relationshipbetween a parent and a child (adolescent).

(c) The model of mutual participation (also advo-cated by Balint (1964)10) is based on the beliefthat equality amongst human beings is mutuallyadvantageous. In this model the doctor does notconfess to know exactly what is best for thepatient. They argued that equality amongsthuman beings is critical to the social structureof egalitarianism and democracy. In order for the concept of mutual participation betweenthe doctor and patient to exist, it is importantthat the interaction between them is based onhaving equal power, mutual independence,and equal satisfaction. This ultimately allowsthe patients to take care of themselves. Themanagement of chronic disease providesa good example. This model therefore pro-vides the patient with a greater degree of


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responsibility and is characterised by a high de-gree of empathy and has elements often associ-ated with friendship and partnership, as well asthe imparting of expert medical advice. There-fore, the doctor’s satisfaction cannot be de-rived from power nor can it stem from the

control over someone else, but rather fr omthe unique service he provides to humanity.3

Patient-centred medicine

‘‘.one of the essential qualities of the clinicians isinterest in humanity, for the secret of the care ofpatients is in caring for the patient’’.3

Over the last 20 years an extensive body of liter-ature has emerged that advocated the patient-centred approach to medical care. The concept of

patient centred medicine can be described andillustrated through the following five key dimen-sions, as proposed by Mead and Bower (2000).14

Biopsychosocial perspective

Stewart et al. (1995)15 assert that the patient-centred approach requires a ‘‘willingness to becomeinvolved in the full range of difficulties patientsbring to their doctors, not just their biomedicalproblems.’’ Also, these authors regarded healthpromotion as an essential component of patient-centred medicine. Lipkin et al. (1984)16 high-lighted the importance of being open to thepatient’s ‘‘hidden agenda’’, reflecting the psycho-analytical influence of the earlier work by Balint(1964).10 Grol et al. (1990)17 proposed that thepatient-centred doctor ‘‘feels responsible for non-medical aspects of problems.’’

The ‘patient-as-person’

A biopsychosocial perspective alone is not suffi-cient for a full understanding of the patient’s

experience of illness, which depends on his or her particular ‘‘biography’’.18 For example, a com-pound leg fracture will not be experienced in thesame way by two different people. They also sug-gested that the medical treatment (even cure) ofdisease does not necessarily alleviate suffering

for all patients. Thus, in order to understandillness and ease the patient’s suffering doctorsmust first understand the personal meaning ofillness for the patient. Mead and Bower (2000)14

suggested that this can have many dimensions;for example, financial insecurity may make apatient reluctant to interpret symptoms as illnessfor fear of being labelled unfit to work. Thus,patient-centred medicine regards the patient asan experiencing individual r ather than the objectof some disease or entity.19 Attending to ‘‘the patient’s story of illness’’20 involves exploring

both the presenting symptoms and the broader lifesetting in which they occur,15 by eliciting each pa-tient’s expectations, feelings and fears about theillness.21 The goal, according to Balint (1964),10 isto ‘‘understand the complaints offered by the pa-tient, and the symptoms and signs found by the

doctor, not only in terms of illnesses, but also as

expressions of the patient’s unique individuality,

his conflicts and problems.’’ Therefore to developa full understanding of the patient’s presentationand provide effective management the doctor should strive to understand the patient as a distinc-tive personality within his or her unique context.

Shared power and responsibility

Mead and Bower (2000)14 advocated the use ofa democratic, equal doctor-patient relationshipdiffering fundamentally from the paternalisticfocus envisaged by Parsons (1951).1 Society advo-cated a shift in the doctor-patient relationshipfrom the ‘guidance-co-operation’ model to ‘mu-tual participation’,5 whereby power and responsi-bility are shared with the patient. Byrne and

Table 1 Three basic models of the doctor-patient relationship (adapted from Szasz and Hollender 1956).5

Reprinted from Arch. Intern. Med. 1956, 97; 585e92. Copyright ª 2006 American Medical Association. All rightsreserved.

Model Physician’s role Patient’s role Clinical applicationof model

Prototypemodel

Activity-passivity Does somethingto the patient

Recipient (unable torespond to inert)

Anaesthesia, acutetrauma, coma,

delirium, etc.

Parent-infant

Guidance-co-operation

Tells patient whatto do

Co-operator (obeys) Acute infectiousprocesses, etc.

Parent-child(adolescent)

Mutualparticipation

Helps patient tohelp himself

Participant in ‘‘partnership’’(uses expert help)

Most chronic illness,psychoanalysis

Adult-adult


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Long (1976)22 suggested that patient-centred con-sultations reflect recognition of patients’ needsand preferences, characterized by behaviourssuch as encouraging the patient to voice ideas,listening, reflecting, and offering collaboration.In this way, patient-centred medicine encouragesmuch greater patient involvement in care than is

generally associated with the biomedical model.

The therapeutic alliance

Patient-centred medicine ensures a far greater priority to the personal relationship between thedoctor and patient, based on psychotherapeuticdevelopments around the concept of the thera-peutic alliance. This notion was supported byRogers (1967),23 who projected that the core ther-apist attitudes of empathy, congruence and uncon-ditional positive regard are both necessary andsufficient for effecting therapeutic change in cli-

ents. More recently, Roth and Fonagy (1996),24emphasized the importance of aspects of thedoctor-patient relationship, including (a) the pa-tient’s perception of the relevance and potencyof interventions offered, (b) agreement over thegoals of treatment, and (c) cognitive and affectivecomponents, such as the personal bond betweendoctor and patient and perception of the doctor as caring, sensitive and sympathetic.25 Thus,a friendly and sympathetic manner may increasethe likelihood of patient adherence to treatment.Conversely negative emotional responses by either

party (e.g. anger, resentment) may serve to com-plicate medical judgment (causing diagnosticerror) or cause patients to default their treatment.A common understanding of the goals and require-ments of treatment is crucial to any therapy,whether physical or psychological (Mead andBower, 2000).14

The ‘doctor-as-person’

Balint et al. (1993)26 described the biomedicalmodel as ‘‘one person medicine’’ in that a satisfac-tory clinical description does not require consider-ation of the doctor. By contrast, patient-centredmedicine is ‘‘two-person medicine’’, wherebythe doctor is an integral aspect of any such de-scription: ‘‘the doctor and patient are influencing each other all the time and cannot be considered

separately’’.26 Sensitivity and insight into the re-actions of both parties can be used for therapeuticpurposes.14 Balint et al. (1993)26 describes howemotions provoked in the doctor by particular patient presentations may be used as an aid tofurther management (‘‘counter-transference’’ ).

Winefield et al. (1996)27 described the dimensionsof patient-centeredness as attention by the doctor to cues of the affective relationship as it developsbetween the parties, including self-awarenessof emotional responses.

The factors influencing

patient-centeredness (see also Fig. 1)

Mead and Bower (2000)14 suggested that a largenumber of variables can potentially influences ofa doctor’s propensity to be patient-centred, bothwithin the context of individual consultations andover the course of the professional career. The di-agram below indicates some of their hypothesizedinfluences. At the centre of the model, is the doc-tor-patient relationship expressed in the form ofa behavioural interaction between two parties.As previously discussed, these behaviours may beinterpreted as more or less patient-centred across

the five dimensions described above.The most distant level, the ‘‘shapers’’ (such as

cultural norms or clinical experience), may impacton more specific determinants (like gender or atti-tudes). For example, norms relating to gender mean that it is more socially acceptable for fe-males to discuss feelings and emotions than males.

The specific context of medical practice mayalso impact on doctors’ patient-centeredness.28

For example, the introduction of videotapedconsultation assessments into the membershipexamination for the Royal College of General Prac-

titioners may encourage more systematic attentionto interpersonal aspects of care by GPs.28 However recent policy initiatives to promote greater teamwork and role substitution among primary care pro-fessionals29 may reduce possibilities for sustainedpersonal contact with individual patients, whichmay prove detrimental to the patient centred ap-proach within the doctor-patient relationship.

Finally, Mead and Bower (2000)14 point out thatthe consultation-level influences have the most im-mediate impact on the propensity of doctors to bepatient centred. For example, ethnic differencesmay create barriers to effective communication.Time or workload pressures may limit possibilitiesfor full negotiation and resolution of conflictbetween the doctor and patient ‘agendas’. Alter-natively, such pressures may increase the valueplaced by a doctor on such aspects of clinicalwork, encouraging adoption of specific mechanisms(e.g. offering longer appointment slots) to facili-tate patient-centred care.

Fig. 1 explicitly recognizes that the propensity ofa doctor to be patient-centred will vary over time,andthatsome dimensions (i.e. thepatient-as-person


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and the doctor-as-person) require significant time todevelop between the doctor and patient. Fig. 2charts the evolution of the doctor-patient relation-ship over time.

Contemporary issues

We have so far considered the evolution of thedoctor-patient relationship in Western civilization.A full discussion of its evolution in other civilizationsis beyond the scope of this paper; however, it is worthnoting that thedoctor-patientrelationship in thetwooldest civilizations, those of India and China, hasremained far more constant than in Western socie-ties. A paternalistic approach still dominates, anddoctors have a high status in society.30 The teachingsof the major Eastern religions, most notably Hindu-ism, Buddhism, and Taoism, deems the art of healingas work most worthy of men, which may partially ac-count for such a high regard in these populations.30

The focus of these civilizations on the different rolesof men and women in society may also be a contribu-tory reason as to why thereis a predominance of menin the medical profession, and many patients, evenfemale, prefer to see male doctors.30 Of course, ex-ceptions such as Moslem women preferring to betreated by female Moslem doctors are notable.30

We would stress though that these statements ex-press generalizations and that the complexities ofthe doctor-patient relationship in these differentcontexts is beyond the scope of this paper.

Another difference between Eastern and West-ern societies is that litigationrates of doctors are far lower in the former civilizations compared to thecontinually escalating negligence claims in the UK,Australia, and particularly, the USA. The elevatedstatus of doctors in Eastern civilizations as men-tioned above is undoubtedly a factor in this. In theWest, medical negligence claims have been revolu-

tionized by the Bolam test31

and Bolitho qualifica-tion32 (that state that the acceptable standard ofcare must be that which ‘no reasonable doctor insimilar position’ fall below,31 and that cour ts wouldreserve the right to make this judgment32). Claimsin the UK have risen 15-fold in the UK since April1995.33 The effect of this has been to erode the doc-tor-patient relationship with higher levels of mutualdistrust, the seeking of second opinions by patients,and often the development of adversarial relation-ships. The UK Department of Health’s consultationdocument, ‘Making Amends’,34 aims to reform thenegligence claims process to make it less adversa-rial, recognising the benefit this will have in restor-ing public confidence in the medical profession.

Another contemporary effect on the doctor-patient relationship has been the exponential in-crease in the use of the Internet by patients. Thishas meant that patients are generally better informed, especially in the more affluent countriesof the West, and this has facilitated the patient-centred approach to health care that predominatestoday. While better patient education has obviousadvantages for the doctor-patient relationship,

Figure 1 The patient-centred model (adapted from Mead and Bower (2000)14). Reprinted from Soc Sci Med , 51,Mead N and Bower P, Patient-centredness: a conceptual framework and review of the empirical literature,pp 1087e110, 2000, with permission from Elsevier.


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there are concerns that information on the Internetmight not always be accurate and reliable.35

This poses a new challenge for the medicalprofessional e that of revising any misinformationthe patient has found him- or her-self.

Conclusion

The chronological evolution of the doctor-patientrelationship has been described. Previously, pa-tients were most often considered to be tooignorant to make decisions on their own behalf.Thus, informing patients about the uncertaintiesand limitations of medical interventions servedonly to undermine the faith that was so essential to

the therapeutic success. Doctors felt comfortablein making decisions on behalf of their patients.Later on, doctors soon became separated fromtheir patients politically, economically, and so-cially. The distance between the doctor andpatient widened. Little social mingling remained,and the doctor-patient relationship became im-personal and remote, based upon negotiation andfinancial transaction. While this was the case for all specialties within Medicine, the extent of thisimpersonality has generally varied, with physiciansbeing more aloof in earlier times, and surgeonsmore so in the 1800s, as a direct result of thestatus placed on them by patients.

Today however there is a new alliance betweenthe doctor and patient, based on co-operation

Ancient Egypt

(approx. 4000 to

1000 B.C.)Healer / doctor dominated

Greek

Enlightenment

(approx. 600 to 100

B.C.)

Partial egalitarianism

Medieval Europe and

the Inquisition

(approx. 1200 to 1600

A.D)

Healer / doctor dominated

The French

Revolution (late

18th century)

Partial egalitarianism

1700s Patient dominated

1800s Doctor dominatedLate 1800s: psychoanalytic and or

psycho-social theories began tofurther constitute the patient as a

subject

1956 Szasz and Hollender: advocating

mutual participation of doctor &

patient

1964The Introduction of Balint’s

Psychodynamic theories

into General Practice

1976 Byrne and Long advocated Patient-Centredness

PRESENT DAY

Continuing research into

patient-centredness

Figure 2 A time line indicating the evolution of the doctor-patient relationship.


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rather than confrontation, in which the doctor must ‘‘understand the patient as a unique humanbeing’’.36 Thus patient-cantered care has replaceda one-sided, doctor-dominated relationship inwhich the exercise of power distorts the deci-sion-making process for both parties. Such an alli-ance must take into account not only the

application of technical knowledge, but also com-munication of information calculated to assist thepatient to understand, control, and cope withoverpowering emotions and anxiety. Doctors mustaccept responsibility for both a technical expertand a supportive interpersonal role. Mutual partic-ipation, respect, and shared decision-making mustreplace passivity. Thus, by dispensing informationin a manner that maximizes understanding is aprerequisite for more equal participation. Balint(1969)36 argued that the patient not the illnessshould be the primary focus of medicine suchthat the primary objective of the doctor is to listen

to the patient in order to identify what the ‘real’problem actually is, instead of simply elicitingsymptoms and signs. Shared decision making be-tween the doctor and patient will determine themost appropriate and best course of action for anindividual patient. The doctor in this patient-centred model is ideally placed to bridge the gapbetween the world of medicine and the personalexperiences and needs of his patients.

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