Doctor-patient relationships in chronic illness: insights from forensic psychiatry

Doctor-patient relationship: Lessons learned from two decades managing patients with HIV

29 March 2005

We welcome the article by Campbell and McGauley (Doctor-patient relationships in chronic illness: insights from forensic psychiatry. BMJ 2005; 330:667-670) identifying an important source of distress for clinicians. We would like to add our perspective and insight from the management of patients living with HIV.

When HIV was first described over 20 years ago infection was characterized by a chronic but ultimately fatal disease course. In the absence of effective therapies management of HIV was overseen by a multidisciplinary team consisting of physicians, nurses, pharmacists and psychologists. Terminal care consisted of symptomatic relief often in the setting of a hospice or specialized HIV ward. This was a challenging time for health care professionals and patients alike and was associated with a high rate of morbidity and mortality. Since the introduction of the first antiretroviral AZT (zidovudine) in the late 1980’s there has been a steady stream of new drugs introduced for the treatment of HIV with around 20 drugs now licensed for the treatment of the disease. This has heralded a new treatment paradigm consisting of drug cocktails (typically 3-4 drugs) known as highly active antiretroviral therapy with patients now living longer and transforming the disease into a chronic albeit serious manageable condition in many patients. Whilst this advance must be welcomed unreservedly it has brought with it further challenges for both patients and the health care team managing patients.

With the availability of 20 different drugs from 4 different classes an almost infinite number of different therapy combinations are possible each with its advantages and disadvantages. Factors that need to be considered include potency, convenience, drug interactions, side effects and the ability to maintain the high levels of adherence that HIV therapy requires to prevent the emergence of drug resistance. Price or adequacy of funding may also play a role in treatment decisions. Tension may therefore arise from the potentially opposing demands of evidence based medicine and patient choice. In particular the advice of the payer in the form of guidelines and the evidence base may be at odds with the preferences of the patient, creating a potential dilemma and source of stress for the clinician. Physicians are under constant pressure to reconcile these differences. Campbell and McGauley identified the importance of medical education; we feel that in addition it is imperative that further research is conducted in order to better understand these pressures. This would also ensure that the education provided was tailored for different clinical management settings.

During the last decade there has been a huge increase in research investigating patient perspectives. While this has improved our understanding of patient needs and beliefs about illness and treatment decisions relatively little research has been published on how this matches physician perspectives and how this may lead to conflicts. Research into the physician perspective is therefore overdue and we would welcome new impetus into this type of research. Only from this type of research can we has heath care providers understand how physicians perceive chronically ill patients and their treatment options and the cognitive and emotional factors influencing their behaviour. In order to develop methods for supporting physicians to be more effective in their communication and delivery of care to chronically ill patients, from prescribing medication to communicating and dealing with medical uncertainty, we need a better understanding of the factors influencing physician behaviour.

Competing interests: None declared

Competing interests: None declared

Robert Horne, Professor of Psychology in Health Care

Martin Fisher

University of Brighton, Falmer Campus, Brighton BN1 9PH, UK

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