Education And Debate

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

BMJ 2005; 330 doi: (Published 17 March 2005) Cite this as: BMJ 2005;330:667

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

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: No competing interests

29 March 2005
Robert Horne
Professor of Psychology in Health Care
Martin Fisher
University of Brighton, Falmer Campus, Brighton BN1 9PH, UK