2003_15

Mike Magee, MD
Mike Magee MD Is the Senior
Fellow in the Humanities to the
World Medical Association and
Director of the Pfizer Medical
Humanities Initiative.
VERTHE PAST DECADES,
a variety of global forces
and trends have collided
and conspired to funda-
mentally transform the delivery of
health care. These forces include the
emergence of the health consumer
movement, the creation of the Internet,
an explosion of scientific discoveries,
the aging of populations worldwide,
the emergence of evidence-based medi-
cine, the monetarization of medicine
with associated evolving strategies for
cost control, and renewed interest in
relationship-based health care models.1
Sociologists like James Coleman2
, Nan
Lin3
and Ron Burt4
have demonstrated
that enduring social relationships are
properly understood as investments in
social capital, which through the recip-
rocal exchange of information and sup-
port, create new resources for individu-
als which otherwise would be impossi-
ble were they to go it alone.
Recent studies in the United States
have revealed that citizens believe the
patient-physician relationship is second
in importance only to family relation-
ship in their society and that it far
exceeds in importance spiritual rela-
tionships, financial relationships and
coworker relationships.5 This relation-
Relationship-Based Health Care in the
United States, United Kingdom, Canada,
Germany, South Africa and Japan
A Comparative Study of Patient and Physician
Perceptions Worldwide
1
O
Author Affiliations, Financial Disclosures, and
Investigators are listed at the end of this article.
Corresponding Author and Reprints: Mike Magee,
MD, Director, Pfizer Medical Humanities Initiative,
235 East 42nd St. New York, NY 10017
Presented at the World Medical Association
“Patient Safety in Care and Research”
September 11, 2003
Context A number of forces have transformed the practice of medicine in the past two decades. Evidence suggests
that these forces are impacting on both patients and physicians and on their relationship with each other.
Objectives To simultaneously survey patients’ and physicians’ perceptions of their relationship with each
other in six countries on four continents.
Design and Setting Patients and physicians were simultaneously studied in six countries using nationally
representative telephone surveys between July 22, 2002 and October 13, 2002. 2506 interviews were con-
ducted on patients (63% response rate) and 1201 interviews were conducted on physicians (58% response
rate) using a random digit dialing (RDD) methodology.
Participants Patients had to be at least 21 years of age. Physicians had to be general practitioners and in
practice for five or more years.
Main Outcome Measures Relative importance of patient-physician relationships compared to other critical
relationships in society. Type of relationship as defined by patients and physicians. Levels of patient empower-
ment and self-management of care. Actual and ideal performance ratings in 5 dimensions in the humanistic
domain (compassion, trust, understanding, patience, listening) and 5 dimensions in the access domain (access
to physician, time with physician, appointment scheduling, choice of treatment, choice of specialist).
Results The patient-physician relationship ranked second in importance to family relationships in all coun-
tries studied. Physicians were the leading source of health information, the most trusted source, and the
source most likely to instigate positive behavioral change in patients in all countries studied. All countries
agree that authoritarian paternalistic relationships between physicians and patients are relatively uncommon
today. These relationships are being replaced by mutual partnerships or advisor models. Patients and physi-
cians in all countries foresee future movement toward partnership and team based models. Compared to 10
years ago, most patients in all countries believe they ask more questions, make more choices, actively evaluate
benefit and risk, and take better care of their own health. Patient’s confidence in managing their own health is
very high in all countries except Japan. Physician confidence in patient’s self-management is lower than
patients scoring in five of the six countries. In general, all cohorts rate physician humanistic performance high-
er than access performance. Physicians in all countries rate their ideal humanistic performance higher than do
patients. In contrast, physicians in the United Kingdom and Germany rate their ideal access performance
lower than the patients’ expectation for ideal access performance. In actual performance both in humanistic
and access domains, physicians score themselves higher than do patients in 8 of the 10 dimensions. Patients
and physicians scoring of opportunities for improvement is relatively well aligned in five of the six countries
studied. The greatest variance in opportunity scores between patient and physician exists in the United
Kingdom in both humanistic domain (17% difference) and access domain (26% difference) and in Germany in
the access domain (19% difference), with patients seeing more opportunity than do physicians.
Conclusions The findings indicate a fundamental shift in the patient-physician relationship away from an
authoritarian and paternalistic model and toward partnership and team based approaches. Patients are signifi-
cantly more confident and empowered than they were ten years ago. Physician confidence in patient self-man-
agement is more modest. Patients possess high confidence in physicians but also demonstrate higher expecta-
tions for ideal physician performance and higher expectations for improvement along five dimensions of
humanistic care and five dimensions of access to care. The ability to align expectations of patients and physi-
cians, and meet commonly held objectives, will be increasingly important in assuring the future health of this
critically important societal relationship.
2
ship was previously defined by more
than 90% of United States patients and
physicians surveyed nationwide as three
things: (1) compassion, (2) understand-
ing, and (3) partnership.6 Additional
studies revealed remarkable evolution
of the relationship over a two-decade
period in the United States including
the initial emancipation of the patient,
their empowerment through patient
education, and active patient engage-
ment in the shaping of our current
health delivery system toward patient-
physician partnerships, team approach-
es and joint risk sharing.7 Since the
forces that are believed to have fueled
this fundamental reshaping of one of
American society’s most fundamental
stabilizing relationships are global in
nature, it was reasonable to hypothesize
that the patient-physician relationship
is actively evolving in other countries as
well. This study was designed to simul-
taneously survey physicians and
patients’ perceptions of their relation-
ships with each other in six countries
on four different continents.
METHODS
The following results are based on 3,707
interviews with doctors and patients
conducted in the United States, United
Kingdom, Canada, Germany, South
Africa and Japan. In order to qualify for
the study, doctors in each country had to
be general practitioners, practicing for
five or more years. Patients had to be at
least 21 years of age.
Interviews in the United States,
United Kingdom, Germany, South
Africa and Japan were conducted
between July 22 and August 30, 2002.
Interviews in Canada were conducted
between September 26 and October 13,
2002. Patients in each country were con-
tacted via telephone using a random
digit dialing (RDD) methodology that
ensures that individuals with listed, as
well as unlisted telephone numbers are
included in the study. 2,506 interviews
were conducted with patients: 500 in
the United States (response rate, 60%),
400 each in the United Kingdom
(response rate, 73%), Germany, South
Africa and Japan, and 406 in Canada.
1,201 interviews were conducted with
doctors; 200 each in the United States,
Canada, Germany, South Africa and
Japan, and 201 in the United Kingdom.
RELATIONSHIP-BASED HEALTH CARE
Table 1. Relative Importance of Relationships
This relationship is extremely/very important to you?
United States United Kingdom Canada Germany South Africa Japan
Family 95 92 94 91 95 71
Doctor 78 63 76 72 80 55
Spiritual Advisor 56 21 32 10 69 27
Co-Worker 51 63 46 64 68 40
Financial Advisor 43 36 35 35 60 19
Pharmacist 48 26 44 34 54 39
Question: Indicate how important the following relationship is to you. (% extremely or very important, 4 or 5 on a scale of 5)
Table 2. Physicians Critical Role as Health Information Resource
Source = Origin of health information
Trust = Trust in information based on source
Action = Willingness to follow recommendations and advice based on source
United States United Kingdom Canada
Source Trust Action Source Trust Action Source Trust Action
Doctor 67 82 98 67 76 91 58 81 95
Pharmacist 27 65 90 51 61 84 28 69 92
Family 42 42 82 69 52 78 36 38 77
Internet 36 21 52 42 17 41 30 17 47
Media 22 11 48 36 15 37 20 15 49
Government 10 20 58 19 17 39 10 21 54
Germany South Africa Japan
Source Trust Action Source Trust Action Source Trust Action
Doctor 81 78 93 53 77 91 66 55 73
Pharmacist 37 50 70 43 65 86 14 34 63
Family 68 52 69 42 43 72 52 36 63
Internet 46 22 29 25 27 40 22 19 36
Media 46 16 29 23 21 33 48 21 53
Government 7 14 22 5 11 25 9 21 47
Questions:
Source: When looking for health information,which of the following do you regularly turn to?
Trust: If you were to receive health information from the following source, how much would you
trust that information? (% great deal or very much, 4 or 5 on a scale of 5)
Action: If you were to receive health information from each of the following sources, how likely
would you be to follow recommendations or advised based treatment based on that information?
(% very likely or somewhat likely, 3 or 4 on a scale of 4)
The margin of error for patients in
the United States is +4.4%. The margin
of error for patients in the United
Kingdom, Canada, Germany, South
Africa and Japan is +4.9%. The margin
of error for doctors in each country is
+6.9%.
FINDINGS
Importance of Relations
In all countries studied, the patient-
physician relationship ranked second in
importance only to family relationships
(Table 1). The percentage gap between
number one and number two rankings
varied as follows: South Africa (15%),
United States (17%), Japan (16%),
Canada (18%), Germany (19%) and
United Kingdom (29%). (Table 1) In
all countries studied, the physician was
viewed by patients as the dominant
source of health information. In addi-
tion, patients had far greater trust in
the accuracy of information coming
from physicians versus other sources
(including pharmacist, family, Internet,
media and government) and were far
more likely to change their health
behavior based on information from a
physician compared to information
from other sources (Table 2).
Confidence levels in physicians (%
having a great deal or fair amount of
confidence) compared to government,
hospitals, corporations and financial
leaders far exceeded all others in all
countries studied (Table 3). Most
patients had a “regular doctor” includ-
ing Germany (88%), United States
(84%), Canada (84%), United
Kingdom (80%), South Africa (80%),
and Japan (73%). Of those who had
regular doctors, large majorities agreed
strongly or somewhat that “my doctor
puts my interests above everything else”
(Japan 92%, South Africa 83%, United
States 80%, Canada 78%, Germany
73%, United Kingdom 72%).
The Relationship
In defining the current patient-
physician relationship, patients in all
countries agree that authoritarian,
paternalistic relationships are relatively
uncommon today. (United Kingdom
20%, United States 17%, South Africa
16%, Canada 13%, Germany 13%,
Japan 12%). Most countries believe the
dominant form of patient-physician
relationship today is a mutual
partnership with 50/50 joint decision
making between patient and physician.
Nearly as many patients in the United
States, United Kingdom, Canada and
Germany believe the current form is
RELATIONSHIP-BASED HEALTH CARE
3
Table 3. Confidence in Physicians
% Above Other Leaders (Great Deal/Fair Amount of Confidence)
United United South
States Kingdom Canada Germany Africa Japan
Religious +23 +44 +36 +49 +23 +21
Government +39 +53 +52 +50 +52 +23
Hospitals +17 +16 +16 +19 +33 +14
Corporations +56 +52 +56 +48 +42 +24
Financial +35 +38 +35 +34 +28 +27
Question:
Thinking about some of the institutions and people with whom you interact, please tell how much
confidence you have in the following (% a great deal or a fair amount, 4 or 5 on a scale of 5)
Table 4. Patient Description of Patient-Physician Relationship
% Describing Relationship With Their “Regular Doctor” as . . .
United United South
States Kingdom Canada Germany Africa Japan
Authoritarian 17 20 13 13 16 12
Mutual Partner 41 41 44 40 55 49
Advisor 37 37 41 45 29 36
Question:
Which of the following best describes your current relationship with your regular doctor:
Authoritarian: Your doctor is an authority figure and in charge of interaction with you.
Mutual Partner: Your doctor is a mutual partner or collaborator, sharing interaction with you
nearly equally.
Advisor: Your doctor is merely an advisor and you are in charge of interaction.
Table 5. Patient Description of Future Patient-Physician Relationship
% Describing Best Relationship for Future as . . .
United United South
States Kingdom Canada Germany Africa Japan
Authoritarian 4 6 5 5 7 3
Mutual Partner 41 35 31 30 51 42
Mutual Team
Partnership 54 58 60 64 42 55
Question:
Thinking about the future of doctor/patient relationships which of the following descriptions of a doc-
tor/patient relationship do you feel would be best in the future:
A compliance oriented relationship where the doctor directs the interaction and determines
treatment, and you only have a small part in making decisions.
A mutual partnership where you and your doctor spend nearly an equal amount of time discussing
diagnosis and possible treatments.
A mutual team partnership where you and a team of health care professionals including your doc-
tor discuss diagnosis and possible treatments and reach conclusions through collaboration.
an advisor model where physicians act
as consultants to patients who in
turn make their own decisions
independently (Table 4). When asked
to define the best relationship for the
future, authoritarian relationships
decline significantly (3% to 7%).
Mutual partnerships emphasizing one
on one joint decision making and
mutual team partnerships, a patient in
a 50/50 partnership with a doctor
lead team that provides both clinical
care and educational support are the
preferred patient visions for the future
(Table 5).
Patient Empowerment
Compared to ten years ago, large
majorities of patients agree that
patients ask more questions (United
States 91%, South Africa 91%, Canada
90%, United Kingdom 89%, Germany
89%, Japan 74%). Most believe that
patients make more choices and active-
ly evaluate benefit and risk more than
did patients ten years ago. (United
States 87%, Canada 84%, South Africa
82%, United Kingdom 79%, Germany
78%, Japan 70%). Most agree as well
that patients take better care of their
own health (Japan 90%, Germany
76%, South Africa 70%, United
Kingdom 68%, Canada 67%, United
States 65%).
In making risk-related decisions,
patients worldwide prefer doctors who
RELATIONSHIP-BASED HEALTH CARE
4
Table 6. Health Consumer Empowerment – Role of Physician in Decision Making
In Making Risk-Related Decisions,Which DoYou Prefer?
United United South
States Kingdom Canada Germany Africa Japan
Doctor takes total responsibility 5 6 6 3 10 4
Doctor provides options
and tells you what to do 26 36 29 33 38 36
Doctor provides options
and leaves decision to you 69 57 63 64 51 60
Not sure 0 1 2 0 1 0
Question: In making risk related decisions, which of the following do you prefer:
A doctor who takes total responsibility for making such a decision and tells you the course of treatments to follow without discussing alternatives.
A doctor who informs you of the alternative treatments and risks, and tells you the treatment he or she will follow unless you disagree.
A doctor who informs you of the alternative treatments and risks, tells you his or her recommendation and leaves it up to you to decide.
Table 7. Patient and Physician Ratings of Ideal Physician Performance
% Who Agree the Ideal Physician Provides (Pt = Patient, Phys = Physician):
United United South
States Kingdom Canada Germany Africa Japan
Pt Phys Pt Phys Pt Phys Pt Phys Pt Phys Pt Phys
Humanistic
Compassion 94 100 85 100 86 94 73 93 73 95 91 98
Trust 97 98 93 100 97 100 91 100 73 91 96 98
Understanding 96 100 92 100 94 96 91 99 70 89 89 96
Patience 94 98 89 99 95 99 91 99 67 84 80 91
Listening 97 99 94 93 94 98 91 99 96 96 66 90
Average 96 99 91 98 93 97 87 98 76 91 84 95
Access
To Doctor 91 98 87 99 93 99 89 97 66 89 84 83
Time With Doctor 90 95 87 78 79 91 87 87 88 93 61 80
Appointment Scheduling 89 92 91 51 88 78 84 71 89 86 57 21
Treatment Choice 96 90 93 70 93 91 95 72 94 92 55 65
Choice of Specialist 92 86 89 82 89 85 86 84 92 78 57 76
Average 92 92 89 76 88 89 88 82 86 88 63 65
Question:
Access Domain: How important would you say it is for doctors to have this in order to establish the best possible relationship with patients?
(% extremely or very important, 4 or 5 on a scale of 5).
Humanistic Domain: Please indicate which of these words or phrases describe the best possible doctor under ideal circumstances (% affirmative).
provide options and leave decisions to
the patient versus doctors who provide
options and tell the patient what to do
or doctors who take total responsibility
(Table 6). Patients’ confidence in man-
aging their own health is very high in
all countries except Japan. Patients are
completely (5 on a scale of 5) or very
confident (4 on a scale of 5) in self
management in the following numbers:
United States 76%, South Africa 72%,
Canada 69%, United Kingdom 66%,
Germany 63%, Japan 15%. 57% of
Japanese patients are somewhat confi-
dent (3 on a scale of 5) and 23% are
not very confident (2 on a scale of 5) in
self-management.
Physician confidence in patient self-
management is lower than patient scor-
ing in five of the six countries including
the United States (-12%), South Africa
(-32%), Canada (-11%), United
Kingdom (-26%), and Germany
(-20%). Japanese physicians are more
confident in patient self-management
than are their patients with 49% believ-
ing all or most patients (4 or 5 on a
scale of 5) know what to do when it
comes to taking care of their general
health, and 39% believing some but
not most (3 on a scale of 5) patients
know what to do.
A majority of patients in five of the
six countries agree that patients should
take the most responsibility for health
care overall in the future including
United Kingdom (71%), South Africa
(63%), Japan (61%), United States
(55%) and Germany (52%). Less than
half of the Canadian patients agree
(43%).
Performance Ratings
Patients and physicians were asked to
RELATIONSHIP-BASED HEALTH CARE
5
Table 8. Patient and Physician Ratings of Current Physicians Performance
% Agree the Current Physician Possesses (Pt = Patient, Phys = Physician):
United United South
States Kingdom Canada Germany Africa Japan
Pt Phys Pt Phys Pt Phys Pt Phys Pt Phys Pt Phys
Humanistic
Compassion 73 84 58 93 71 90 51 74 57 70 56 71
Trust 87 84 77 98 89 97 76 92 62 86 69 67
Understanding 77 88 65 97 80 93 71 86 63 76 52 57
Patience 70 64 55 75 74 63 58 64 56 55 44 62
Listening 77 92 64 78 68 89 79 92 79 92 45 73
Average 77 84 64 88 76 86 67 82 63 76 53 66
Access
To Doctor 60 67 47 78 60 55 70 79 55 65 47 61
Time With Doctor 66 83 54 49 58 69 63 73 76 82 33 57
Appointment Scheduling 63 84 42 48 53 64 75 78 74 68 38 22
Treatment Choice 73 87 54 68 64 84 65 81 76 85 42 72
Choice of Specialist 70 83 49 67 63 66 60 87 78 89 36 58
Average 66 81 49 62 60 68 67 80 72 78 39 54
Question:
Humanistic Domain: Do each of the following words or phrases describe most doctors? (% affirmative).
Access Domain: How satisfied would you say you are in this area? (% extremely or very satisfied, 4 or 5 on a scale of 5).
Table 9. Average Opportunity Ratings: Patient and Physician Perceptions of
Opportunity for Improved Physician Performance (Difference Between
Average Ideal and Actual)
United United Ger- South
States Kingdom Canada many Africa Japan
Humanistic Domain:
Average of 5 dimensions:
Patient Opportunity Rating 19 27 17 20 13 31
Physician Opportunity Rating 15 10 11 16 15 29
Perception Gap 4 17 6 4 2 2
Access Domain:
Average of 5 dimensions:
Patient Opportunity Rating 26 40 28 21 14 24
Physician Opportunity Rating 11 14 21 2 10 11
Perception Gap 15 26 7 19 4 13
Note: Opportunity Rating = Ideal Rating – Current Rating
evaluate the ideal physicians’ perform-
ance in five humanistic domains and
five access domains. They were then
asked to rate current physician per-
formance in each of these areas. The
gaps between ideal and reality or the
opportunity rating were then calculated
by simple subtraction and highlight
patients and physicians’ perceptions of
opportunity for improvement in physi-
cian performance in each of these
dimensions. Humanistic domains
included compassion, trust, under-
standing, patience, partnering and lis-
tening. Access domains included access
to doctor, time spent with doctor, ease
of appointment scheduling, access to
varied treatment options and access to
specialists.
Ideal physician ratings are displayed
in Table 7. They reflect the patients and
physicians’ perspectives of what should
be possible in physician performance
under ideal circumstances in each
country. Displayed are five humanistic
and five access dimensions as well as
average scores in each domain.
In general all cohorts are more opti-
mistic regarding possibilities for
humanistic performance than for access
performance with ideal humanistic
scores exceeding ideal access scores by
an average 4 points by patients and 14
points by physicians respectively. In all
countries studied physician’s average
humanistic scores in the ideal exceed
patients. In contrast, physicians’ aver-
age ideal access scores fall below expec-
tations in the ideal set by patients in the
United Kingdom (13 points), and in
Germany (6 points).
Current ratings of physicians are dis-
played in Table 8. They reflect the
patients and physicians’ perspectives of
what current performance of physicians
is in each country. When compared to
ideal ratings the difference demon-
strates perceived opportunities for
improvement in physician performance
toward the ideal. The level of opportu-
nity is affected by both the level of
expectation as expressed in the ideal
score and the measure of today’s reality
reflected in the current score. In all
countries studied current physicians
performance as an average of all dimen-
sions of both humanistic and access
domains are scored higher by physi-
cians than by patients by an average 12
points in the aggregate. Patients and
physicians in the United States, United
Kingdom, Canada and Japan score cur-
rent humanistic performance higher
than current access performance.
Table 9 displays Opportunity
Ratings (the difference between ideal
and current ratings) for improved
physician performance in humanistic
and access domains by country. Patients
perceive the greatest opportunities for
humanistic advances in the United
Kingdom and Japan and the greatest
opportunities for access advances in the
United Kingdom, Canada and the
United States. Patient and physician
perceptions of opportunity for
improvement are relatively well aligned
in the United States, Canada, South
Africa and Japan. The greatest variance
in patient and physician point of view
exists in the United Kingdom in both
the humanistic domain (17% differ-
ence) and access domain (26% differ-
ence), and in Germany in the access
domain (19% difference).
COUNTRY PROFILES
United States
In the United States, the patient-physi-
cian relationship is viewed by 78% of
patients as extremely or very important.
This compares to 95% for family rela-
tions, 56% for spiritual relations, 51%
for co-worker relations and 43% for
financial relations. United States
patients’ confidence in physicians
exceeds other societal leaders from gov-
ernment (+39%), industry (+56%),
financial sector (+35%), religious com-
munity (+23%) and hospital industry
RELATIONSHIP-BASED HEALTH CARE
Table 10. United States: Physician Current Performance and Opportunity Ratings (Parenthesis)
Current
Humanistic
Rating Compassion Trust Understanding Patience Listening
Patients (Opportunity Rating) 73(11) 87(10) 77(19) 70(24) 77(20)
Physicians (Opportunity Rating) 84(16) 84(14) 88(12) 64(34) 92(7)
Perception Gap 11(5) 3(4) 11(7) 6(10) 15(13)
Current
Access Access to Time Spent Appointment Access to Access to
Rating Doctor With Doctor Scheduling Treatment Specialists
Patients (Opportunity Rating) 60(31) 66(24) 66(23) 73(23) 70(22)
Physicians (Opportunity Rating) 67(31) 83(10) 84(8) 87(3) 83(3)
Perception Gap 7(0) 17(14) 22(15) 14(20) 13(19)
Question:
Humanistic Domain: Do each of the following words or phrases describe most doctors? (% affirmative).
Access Domain: How satisfied would you say you are in this area? (% extremely or very satisfied, 4 or 5 on a scale of 5).
Note: Opportunity Rating = the difference between Ideal Physician Score and Current Physician Score.
6
(+17%). 48% of United States patients
agree strongly that “my doctor puts my
interests above everything else”, while
32% agree somewhat with this state-
ment. Physicians are the leading source
of health information (67%), the most
trusted source of health information
(82%) and the most likely source to
instigate positive health behavioral
change (98%).
Patients in the United States are
highly evolved as health consumers.
76% of patients are completely or very
comfortable in managing their own
general health while 40% of physicians
are completely or very comfortable
with patient’s self management and
39% of physicians are somewhat confi-
dent in patient self management.
Patients (69%) and physicians (63%)
agree in the majority that in making
risk-related decisions with patients, the
doctor should provide options and
leave the decision to the patient rather
than tell the patient what to do.
A minority of United States patients
(17%) and physicians (19%) see them-
selves in an authoritarian doctor-driven
patient-physician relationship. The
majority of physicians (73%) and
patients (41%) identify a mutual part-
nership with joint decision making as
their current model. A significant num-
ber of patients (37%) identify their
relationship as a more independent advi-
sor model, where physician provides
information and patients make inde-
pendent decisions. In viewing the pre-
ferred model relationship for the future
93% of physicians and 95% of patients
favor partnership models over authori-
tarian ones and 52% of physicians and
54% of patients support the movement
toward team-based approaches.
United States patients and physicians
share in common high expectations for
ideal physician performance (Table 7).
Average ideal physician humanistic rat-
ings of five humanistic dimensions are
96% by patients and 99% by physi-
cians. Average ideal physician access
ratings of five access dimensions are
92% by patients and 92% by physician.
Patients and physicians share as well
common expectations for improvement
including 19% (patients) and 15%
(physicians) upgrades in average
humanistic performance and to a lesser
degree in average access performance at
26% (patients) and 11% (physicians)
(Table 9).
In rating current performance in
individual dimensions in the humanis-
tic domain, ratings are lowest by
patients and physicians for patience
(patients – 70% with a 24% opportu-
nity for improvement, and physicians –
64% with a 34% opportunity for
improvement). Scores in current per-
formance in access dimensions are
moderately high by patients (66% to
73%) and somewhat higher by physi-
cians (67% to 87%) with patients see-
ing greater opportunity for improve-
ment than do physicians in four of the
five dimensions (Table 10).
United Kingdom
In the United Kingdom the patient-
physician relationship is viewed by
63% of patients as extremely or very
important. This compares to 92% for
family relations. Co-worker relations
(63%) score relatively high in the
United Kingdom compared to other
countries and far exceed spiritual rela-
tions (21%) and financial relations
(36%). Confidence in physicians by
patients in the United Kingdom is high
compared to other leaders far exceeding
government (+39%), corporations
(+56%), financial community (+34%),
religious community (+23%), and hos-
pitals (+17%). 33% of United
Kingdom patients agree strongly that
“my doctor puts my interests above
everything else,” while 40% agree
somewhat with this statement.
Physicians at 67% are the second lead-
ing source of health information (next
to families 69%), but are the most
trusted (76%) and most likely to insti-
RELATIONSHIP-BASED HEALTH CARE
7
Table 11. United Kingdom: Physician Current Performance and Opportunity Ratings (Parenthesis)
Current
Humanistic
Rating Compassion Trust Understanding Patience Listening
Patients (Opportunity Rating) 58(27) 77(16) 65(27) 55(34) 64(30)
Physicians (Opportunity Rating) 93(7) 98(2) 97(3) 75(24) 78(15)
Perception Gap 35(20) 21(14) 32(24) 20(10) 13(15)
Current
Access Access to Time Spent Appointment Access to Access to
Rating Doctor With Doctor Scheduling Treatment Specialists
Patients (Opportunity Rating) 47(40) 54(33) 47(49) 54(39) 49(40)
Physicians (Opportunity Rating) 78(21) 49(29) 48(3) 68(2) 67(15)
Perception Gap 31(19) 6(4) 6(46) 14(37) 18(25)
Question:
Humanistic Domain: Do each of the following words or phrases describe most doctors? (% affirmative).
Access Domain: How satisfied would you say you are in this area? (% extremely or very satisfied, 4 or 5 on a scale of 5).
Note: Opportunity Rating = the difference between Ideal Physician Score and Current Physician Score.
gate positive health behavioral change
(91%). Patients in the United
Kingdom are well evolved as health
consumers with 70% completely or
very confident in managing their own
health and 22% somewhat confident.
Only 28% of physicians in the United
Kingdom are completely or very confi-
dent in patients taking the right actions
to manage their own health with 41%
of physicians somewhat confident and
24% of physicians not very confident.
This is in spite of the fact that 91% of
physicians and 71% of patients in the
United Kingdom agree that patients
currently do take the most responsibili-
ty for their own health. While the
majority of patients (57%) and physi-
cians (50%) believe that in making
risk-related decisions with patients they
prefer a doctor who provides options
and leaves the decision to the patient, a
significant number of patients (36%)
and physicians (50%) prefer a doctor
who provides options and tells the
patient what to do.
A minority of United Kingdom
patients (20%) and physicians (10%)
see themselves in an authoritarian doc-
tor driven patient-physician relation-
ship. The majority of physicians (76%)
and patients (41%) identify a mutual
partnership with joint decision making
as their current model. A significant
number of patients (37%) identify
their relationship as an independent
advisor model, where physician pro-
vides information and patient makes
independent decisions. In viewing the
preferred model relationship for the
future, 93% of patients and 92% of
physicians favor partnership models to
authoritarian ones. In addition patients
(58%) support movement toward
team-based approaches to a greater
degree than do physicians (35%).
United Kingdom patients and physi-
cians demonstrate moderate variance in
their expectations for ideal physician
performance (Table 7). While physi-
cians rate ideal performance for the
humanistic domains at 98%, patients
place their expectation at 91%.
Conversely patients rate the ideal
physician performance in access
domains at 89% while physicians
expectation of access in the ideal is
rated at only 76%. Patients and physi-
cians in the United Kingdom diverge as
well in their expectations for improve-
ment. Patients foresee an average 27%
potential for improvement in the
humanistic domain and 40% potential
for improvement in the access domain
while physicians see only the opportu-
nity for a 10% and a 14% improve-
ments in humanistic and access
domains respectively (Table 9).
In rating current humanistic per-
formance, physician scores are high in
three dimensions and moderate in two
while patients scores are moderate in
three and low in two. In addition,
patients see greater potential for
improvement than do physicians with
opportunity ratings exceeding those of
physicians by 20% for compassion and
24% for understanding. Access dimen-
sions are scored low by patients and
moderate to low by physicians. Most
notable is a striking difference in opin-
ion on opportunity for improvement
in access with patients opportunity rat-
ings exceeding physicians by 46% in
appointment scheduling, 37% in access
to treatments and 25% in access to spe-
cialists (Table 11).
Canada
In Canada, the patient-physician rela-
tionship is viewed by 74% of patients
as extremely or very important. This
compares with 94% for family rela-
tions, 46% for co-worker relations,
35% for financial relations and 32%
for spiritual relations. Confidence in
physicians by patients in Canada is
high compared to other leaders far
exceeding leaders in government
(+52%), corporations (+56%), finan-
cial community (+35%), religious
community (+36%) and hospitals
(+16%). 41% of Canadian patients
agree strongly that “my doctor puts my
interests above everything else,” while
RELATIONSHIP-BASED HEALTH CARE
8
Table 12. Canada: Physician Current Performance and Opportunity Ratings (Parenthesis)
Current
Humanistic
Rating Compassion Trust Understanding Patience Listening
Patients (Opportunity Rating) 71(15) 89(8) 80(14) 74(21) 68(26)
Physicians (Opportunity Rating) 90(4) 97(3) 93(3) 63(36) 89(9)
Perception Gap 19(11) 8(5) 13(11) 11(15) 21(17)
Current
Access Access to Time Spent Appointment Access to Access to
Rating Doctor With Doctor Scheduling Treatment Specialists
Patients (Opportunity Rating) 60(33) 58(21) 53(35) 64(29) 63(26)
Physicians (Opportunity Rating) 55(44) 69(22) 64(14) 84(7) 66(19)
Perception Gap 5(11) 11(1) 11(21) 20(22) 3(7)
Question:
Humanistic Domain: Do each of the following words or phrases describe most doctors? (% affirmative).
Access Domain: How satisfied would you say you are in this area? (% extremely or very satisfied, 4 or 5 on a scale of 5).
Note: Opportunity Rating = the difference between Ideal Physician Score and Current Physician Score.
37% agree somewhat with this state-
ment. Physicians at 58% are the lead-
ing source of health information with
families rating second at 36%.
Physicians are also the most trusted
source of information (81%) and the
source most likely to instigate positive
health behavioral change (95%).
Patients in Canada are significantly
evolved as health consumers with 79%
either completely or very confident
that they take the right actions in man-
aging their own health compared to
34% of Canadian physicians who
believe the same to be true. 58% of
physicians and 43% of patients agree
that patients currently take the most
responsibility for their health. A major-
ity of physicians (69%) and patients
(63%) prefer a doctor who provides
options and leaves decisions to the
patients in making risk-related deci-
sions. Less than one third of doctors
(31%) and patients (29%) prefer a
doctor who provides options and tells
the patients what to do under these
circumstances.
A minority of Canadian patients
(13%) and physicians (10%) see them-
selves in an authoritarian doctor-driv-
en patient-physician relationship. The
majority of physicians (70%) and
patients (44%) identify a mutual part-
nership with joint decision making as
their current model. A significant
number of patients (41%) identify
their relationship as an independent
advisor model, where physician pro-
vides information and patient makes
independent decisions. In viewing the
preferred model relationship for the
future, 91% of patients and 94% of
physicians support partnership models
over authoritarian ones. In addition,
60% of patients and 52% of physicians
support movement to team-based
approaches.
Canadian patients and physicians
show little variance in their expecta-
tions for ideal physician performance
on humanistic scales (patients 93%,
physicians 97%) or access scales
(patients 88%, physicians 89%) (Table
7). Canadian patients and physicians
also see similar room for improvement
in both humanistic (patients 17%,
physicians 11%) and access (patients
28%, physicians 21%) scales (Table 9).
In rating current performance in
individual dimensions in the humanis-
tic domain, ratings by patients are
moderate and ratings by physicians are
high except for patience (63%). In
patience, patients and physicians see
significant room for improvement
(21% and 36%). In current access rat-
ings patients grades are low as are
physicians except for access to treat-
ments where physicians rate 84% while
patients rate 64%. Patients and physi-
cians agree generally in high opportu-
nity potential (19% to 44%) in access
to doctor, time spent with doctor and
access to specialists. However visions
for improvement in appointment
scheduling and access to treatments
vary by 21% and 22% respectively
with patients more optimistic than
physicians (Table 12).
Germany
In Germany the patient-physician
relationship is viewed as extremely or
very important by 72% of patients. This
compares with 91% for family relations,
35% for financial relations, 64% for co-
worker relations, and 10% for spiritual
relations. Confidence in physicians by
patients in Germany is high compared
to other leaders far exceeding leaders in
government (+50%), corporations
(+48%), financial community (+34%),
religious community (+49%), and
hospitals (+19%). 33% of German
patients agree strongly that “my doctor
puts my interests above everything else,”
while 40% agree somewhat with this
statement. German physicians at 81%
are the leading source of health
information with families rated second
at 68%. Physicians are also the most
trusted source of information (78%),
RELATIONSHIP-BASED HEALTH CARE
9
Table 13. Germany: Physician Current Performance and Opportunity Ratings (Parenthesis)
Current
Humanistic
Rating Compassion Trust Understanding Patience Listening
Patients (Opportunity Rating) 51(22) 76(15) 71(20) 58(33) 79(12)
Physicians (Opportunity Rating) 74(19) 92(8) 86(13) 64(35) 92(7)
Perception Gap 23(3) 16(7) 15(7) 6(2) 13(5)
Current
Access Access to Time Spent Appointment Access to Access to
Rating Doctor With Doctor Scheduling Treatment Specialists
Patients (Opportunity Rating) 70(19) 63(24) 75(9) 65(30) 60(26)
Physicians (Opportunity Rating) 79(18) 73(14) 78(-7) 81(-9) 87(-3)
Perception Gap 9(1) 10(10) 3(16) 16(39) 27(31)
Question:
Humanistic Domain: Do each of the following words or phrases describe most doctors? (% affirmative).
Access Domain: How satisfied would you say you are in this area? (% extremely or very satisfied, 4 or 5 on a scale of 5).
Note: Opportunity Rating = the difference between Ideal Physician Score and Current Physician Score.
and the source most likely to instigate
positive health behavioral changes
(93%).
Patients in Germany are well evolved
as health consumers with 73% of
German patients completely or very
confident that they take the right
actions in managing their own health.
Approximately one-quarter of German
patients (26%) are only somewhat or
not very confident in patient self-
management of general health. A
majority of patients (64%) and a
minority of physicians (44%) prefer a
doctor who provides options and leaves
decisions to patients when confronting
a risk-related decision. In contrast, a
majority of physicians (53%) and a
minority of patients (33%) prefer a
doctor who provides options and tells
patients what to do under similar
circumstances.
A minority of German physicians
(14%) and patients (13%) see
themselves currently in an
authoritarian doctor-driven patient-
physician relationship. A majority of
physicians (66%) and a minority of
patients (40%) identify a mutual
partnership with joint decision making
as their current model. A majority of
patients (45%) and a minority of
physicians (16%) identify their
relationship as an independent advisor
model where physician provides
information and patient makes
independent decisions. In viewing the
preferred model relationship for the
future, 20% of German physicians
choose an authoritarian model in
contrast to 5% of German patients.
The majority of physicians (80%) and
patients (94%) prefer partnership
models over authoritarian ones. In
addition, 64% of patients and 53% of
patients support movement toward
team-based approaches.
German patients and physicians
show mild variance in their
expectations for ideal physician
performance on humanistic scales
(patients 87%, physicians 98%) and
access scales (patients 88%, physicians
82%) (Table 7s). Patients and
physicians show mild variance in room
for future improvement in average
humanistic performance (patients
20%, physicians 16%) and moderate
variance in room for improvement in
average access performance (patients
21%, physicians 2%) (Table 9).
In rating current performance in
individual dimensions in the
humanistic domain, physicians and
patients scores are moderate to low.
Greatest variation between patients and
physician scoring occurs in compassion
(23% difference). Opportunity ratings
in the humanistic domain show
patients and physicians well aligned. In
rating current performance in
individual dimensions in the access
domain, scoring by physicians is
moderate and by patients moderate to
low. Greatest variance exists in access to
treatment (16% difference) and access
to specialists (27% difference). In
addition, physicians are significantly
more pessimistic in their opportunity
ratings which differ from patient
ratings by 31% for access to specialists,
39% for access to treatments and 16%
for appointment scheduling (Table 13).
South Africa
In South Africa, the patient-physician
relationship is viewed by 80% of
patients as extremely or very important.
This compares with 95% for family
relations, 68% for co-worker relations,
60% for financial relations and 69%
for spiritual relations. Confidence in
physicians by South African patients is
high compared to other leaders far
exceeding leaders in government
(+52%), corporations (+42%), finan-
cial community (+28%), religious com-
munity (+23%), and hospitals (+33%).
56% of South African patients agree
strongly that “my doctor puts my inter-
ests above everything else,” while 27%
agree somewhat with this statement.
RELATIONSHIP-BASED HEALTH CARE
10
Table 14. South Africa: Physician Current Performance and Opportunity Ratings (Parenthesis)
Current
Humanistic
Rating Compassion Trust Understanding Patience Listening
Patients (Opportunity Rating) 57(16) 62(11) 63(7) 56(11) 79(17)
Physicians (Opportunity Rating) 70(25) 86(5) 76(13) 55(29) 92(4)
Perception Gap 23(9) 24(6) 13(6) 1(18) 13(13)
Current
Access Access to Time Spent Appointment Access to Access to
Rating Doctor With Doctor Scheduling Treatment Specialists
Patients (Opportunity Rating) 55(11) 76(12) 74(15) 76(18) 78(14)
Physicians (Opportunity Rating) 65(24) 82(11) 68(18) 85(7) 89(-11)
Perception Gap 10(13) 6(1) 6(3) 9(11) 11(25)
Question:
Humanistic Domain: Do each of the following words or phrases describe most doctors? (% affirmative).
Access Domain: How satisfied would you say you are in this area? (% extremely or very satisfied, 4 or 5 on a scale of 5).
Note: Opportunity Rating = the difference between Ideal Physician Score and Current Physician Score.
Physicians at 53% are the leading
source of health information with fam-
ilies (42%) and pharmacists (43%) on a
second tier. Physicians are also the most
trusted source (77%) and the source
most likely to instigate positive behav-
ioral change (91%).
Patients in South Africa are signifi-
cantly evolved as health consumers
with 76% completely or very confident
that they take the right actions in man-
aging their own health compared to
24% of South African physicians who
share this belief. 68% of physicians are
somewhat or not very confident in
South African patient self-manage-
ment. A majority of patients (51%) and
a minority of physicians (44%) prefer a
doctor who provides options and leaves
decisions to patients when faced with
risk related decisions, while a majority
of physicians (54%) and minority of
patients (38%) prefer a doctor who
provides options and tells the patient
what to do under similar circum-
stances.
A minority of South African patients
(16%) and physicians (10%) see them-
selves in an authoritarian doctor-driven
patient-physician relationship. The
majority of physicians (79%) and
patients (55%) identify their relation-
ship as a mutual partnership marked by
joint decision making. A minority of
doctors (11%) and patients (29%)
identify their relationship as an inde-
pendent advisor model with doctors
providing information and patients
making decisions independently. In
viewing the preferred model relation-
ship for the future, 93% of patients and
96% of physicians support partnership
models over authoritarian ones. In
addition 42% of patients and 57% of
physicians support movement toward
team-based approaches.
South African patients and physi-
cians show moderate variance in their
expectations for ideal physician per-
formance on average humanistic scales
(patients 76%, physicians 91%) but lit-
tle variance in their expectations for
ideal access performance (patients
86%, physicians 88%) (Table 7). South
African patients and physicians largely
agree on average opportunity ratings
both in humanistic performance
(patients 13%, physicians 15%) and in
access performance (patients 14%,
physicians 10%) (Table 9).
In rating current performance in the
individual dimensions in the humanis-
tic domain, patients and physicians
scores are highly variable. The greatest
variance between patients and physi-
cians is in compassion and trust (physi-
cians rate these 23% and 24% higher
respectively than do patients).
Physicians see greater opportunity for
improvement in patience (18% differ-
ence) than do patients. In current
access ratings, scoring by patients and
physicians is moderate to low with mild
variability between the two groups.
Patients and physicians see similar
opportunities for improvement in
access dimension except in access to
specialists where patients see a 25%
greater opportunity for improvement
than do physicians (Table 14).
Japan
In Japan, the patient-physician relation-
ship is viewed by 55% of patients as
extremely or very important compared
with 71% for family relations, 40% for
co-worker relations, 19% for financial
relations and 27% for spiritual relations.
Confidence in physicians in Japan
exceeds other leaders in government
(+23%), corporations (+24%), financial
industry (+27%), religious community
(+21%) and hospitals (+14%). 39% of
Japanese patients agree strongly that
“my doctor puts my interests above
everything else,” while 53% agree some-
what with this statement. Physicians are
identified as the leading source of health
information (66%) with family second
(52%). Physicians are also the most
trusted resource (55%) and most likely
to instigate positive behavioral
change (73%).
Patients in Japan are less evolved as
health consumers than in other nations
RELATIONSHIP-BASED HEALTH CARE
11
Table 15. Japan: Physician Current Performance and Opportunity Ratings (Parenthesis)
Current
Humanistic
Rating Compassion Trust Understanding Patience Listening
Patients (Opportunity Rating) 56(35) 69(27) 52(37) 44(36) 45(21)
Physicians (Opportunity Rating) 71(27) 67(31) 57(39) 62(29) 73(17)
Perception Gap 15(8) 2(4) 5(2) 18(7) 28(4)
Current
Access Access to Time Spent Appointment Access to Access to
Rating Doctor With Doctor Scheduling Treatment Specialists
Patients (Opportunity Rating) 47(37) 33(28) 38(19) 42(13) 36(21)
Physicians (Opportunity Rating) 61(22) 57(23) 22(-1) 72(-7) 58(18)
Perception Gap 14(15) 24(5) 16(20) 31(20) 22(3)
Question:
Humanistic Domain: Do each of the following words or phrases describe most doctors? (% affirmative).
Access Domain: How satisfied would you say you are in this area? (% extremely or very satisfied, 4 or 5 on a scale of 5).
Note: Opportunity Rating = the difference between Ideal Physician Score and Current Physician Score.
studied with only 28% completely or
very confident that they take the right
actions in managing their own health.
Japanese physicians are generally in
agreement with 22% completely or
very confident in patient self-manage-
ment. The vast majority of patients
(58%) and physicians (57%) are some-
what confident of patients self manage-
ment or not very confident (patients
10%), physicians (17%). Patients
(60%) and physicians (57%) in Japan
prefer a doctor who provides options
and leaves decisions to patients when
faced with risk related decisions. A
smaller but significant number of
patients (36%) and physicians (39%)
prefer a doctor who provides options
and tells the patient what to do under
these circumstances.
A minority of patients (12%) and
physicians (4%) currently see them-
selves in authoritarian doctor driven
patient-physician relations. A majority
of patients (49%) and a large majority
of physicians (84%) currently define
their relationship as a mutual partner-
ship marked by joint decision making.
A large minority of patients (36%) and
a small minority of physicians (11%)
see their relationship as an independent
advisor role with physicians providing
information and patients making inde-
pendent decisions. In viewing the pre-
ferred model for the future, the majori-
ty of patients (97%) and physicians
(92%) prefer partnership models over
authoritarian ones. In addition 55% of
patients and 58% of physicians foresee
movement toward team-based
approaches.
Japanese patients and physicians
show little variation in their expecta-
tions for ideal physician performance
on average humanistic scales (patients
84%, physicians 95%) and on average
access scales (patients 63%, physicians
65%) (Table 7). Expectations for ideal
access are significantly lower in Japan
than in any other country studied.
Japanese patients and physicians are in
close agreement and see large areas for
improvement in average physician
humanistic performance (patients
31%, physicians 29%). Expectations
for gains in access performance are
more modest (patients 24%, physicians
11%) (Table 9).
In rating current performance in
individual dimensions in the humanis-
tic domain, Japanese patients and
physicians provide low scores with little
variability between patient and physi-
cian assessment except in listening
where physicians rating exceeds
patients by 28%. Yet patients and
physicians are optimistic for the future,
seeing high opportunity for improve-
ment across all dimensions with little
variability between patient and physi-
cian perception. Low scores dominate
as well in the current access dimensions
with patients scoring time spent with
doctor, access to treatments and access
to specialists 24%, 31%, and 22%
lower than do physicians respectively.
Patients and physicians have similar
opportunity ratings in access to doc-
tors, time spent with doctor and access
to specialists, but doctors see less
opportunity than do patients for
improvements in appointment schedul-
ing and access to treatments by 20%
and 20% respectively (Table 15).
Discussion
Democracies are relationship based
societies infused by two integrated
themes: individualism, marked by both
rights and responsibilities and commu-
nity, marked by principles of civility,
respect for law and active expressions of
citizenship. Stability and progress rely
on highly functional and enduring rela-
tionships capable of capturing learnings
and transmitting them intergenera-
tionally and securing an environment
that is durable, forward looking and
optimistic8
.
Enduring relationships are recogniza-
ble as real and formative rather than
superficial in so far as individuals who
actively care for each other, give mean-
ing to each other as participants in
something larger than their own limit-
ed self interest. Enduring relationships
are committed, that is they resist sepa-
ration and unite individuals who pro-
vide each other with real time feedback
designed to strengthen their bonds
through mutual self improvement.
Such feedback requires a supportive
societal environment marked by facili-
tated partner contact and open access
to information. Societal support of
such relationships represents an invest-
ment in social capital or the creation of
new resources unable to be realized by
individuals working independently in a
non-cooperative fashion.2 3 4 8
In the six countries surveyed the
patient-physician relationship is highly
valued by citizens, second only in
importance to family relationships.
Prior studies have defined this relation-
ship in over 90% of patients and physi-
cians as possessing three key elements:
compassion, understanding and part-
nership.5
While the deeply personal
nature of the engagement in part
explains its power in each of these soci-
eties, it does not fully define its purpose
or value to those societies. On one level
this relationship delivers what we
would quite literally expect and that is
individual evaluation and treatment of
medical conditions and the provision of
increasingly preventive oriented infor-
mation and council through remark-
ably decentralized and pervasive grass-
roots networks.9
A secondary benefit
that is somewhat less visible is a
byproduct of this partnership and that
is the reinforcement of the integrity of
the family unit as relatives and loved
ones are intentionally included and
immersed in meeting the challenges of
medical conditions or planning preven-
tion for the patient in order to secure a
brighter family future10
. A third func-
tion, largely taken for granted, is the
capacity of these relationships, exer-
cised some 750 million times a year in
the United States alone, in the aggre-
gate, to absorb, process and manage the
daily fears and worries of a populace in
a constructive, well controlled and
hopeful manner11
. Finally, as a fourth
role, transmitted progressively from
individual, to family, to community
and to society, is the creation of gener-
al confidence and trust on the macro
RELATIONSHIP-BASED HEALTH CARE
12
level that our day to day world is rela-
tively safe, somewhat protected and
generally hopeful and therefore worth
the daily investment of our human,
social and financial capital.2 3 4 8 12
To accomplish these four highly inte-
grated objectives, the patient-physician
relationship has been aggressively
redefining itself over the past two
decades. The emancipation of patients
embodied in the realization and accept-
ance of personal responsibility for one’s
own health management gained cre-
dence as part of the civil rights move-
ment in the 1980’s1
. Fueled by the
Internet, general support from a widen-
ing array of caregivers and an enlight-
ened self interest, patients correctly
identified education as the lever that
would empower them to move with
their physician toward new partnership
and team approaches and away from
passive dependence on authoritarian
based models13
. Now facing the chal-
lenges of aging with the emergence of
four- and five-generation families, an
expansion of scientific understanding
and new discoveries, an increasing
emphasis on health prevention as a
responsibility not only to oneself and
one’s family, but also to one’s commu-
nity and society, a more enlightened
understanding of the impact of state
policies and approaches on this most
fundamental and dynamic societal rela-
tionship is emerging.
While this study clearly reveals that
the evolution of the patient-physician
relationship is a worldwide phenome-
non, the speed, readiness, and stresses
felt vary somewhat from culture to cul-
ture. The comparative studies reveal
variability in the alignment of expecta-
tions of patients and physicians in the
ideal, and in their current reality in
both humanistic performance of physi-
cians and access performance of physi-
cians. To fully realize the potential of
the patient-physician relationship to
deliver the care, reinforce cooperative
networks, and act as a societal stabiliz-
er, the relationship must manage serv-
ice on the micro level in a manner that
accumulates social capital to advantage
communities and societies on a macro
level. This requires at a minimum social
policy that draws physicians and
patients closer together rather than far-
ther apart giving them the opportunity
to participate and advocate for each
other.
It requires as well a relatively well-
aligned vision by both patient and
physician of what is excellence (ideal
performance) and what is the current
opportunity for improvement (the dif-
ference between ideal and actual per-
formance). Patient expectations are
affected by their level of emancipation
and empowerment as health consumers
which in turn is a function of the level
of educational and emotional support
provided by physicians and other care-
givers to the patient14
. Physician aspira-
tions are affected by their general sup-
port for patient emancipation, empow-
erment, and team approaches tempered
by their perceptions of what is realistic
in light of the available resources and
the level of function or dysfunction of
their health delivery system15
. In gener-
al, a highly dysfunctional system would
be expected to prevent a physician from
providing the access and advocacy he
would ideally choose to provide in sup-
port of the patient. Over time, such
obstacles would be expected to artifi-
cially depress what the physician would
consider to be ideally acceptable lead-
ing him to accept a lower goal as the
best he can do under the circumstances.
Given more time, a performance ideal
that would initially be unacceptable
gradually and grudgingly becomes
acceptable. In contrast, the patient,
newly empowered and progressively
more educated (with or without the
physician) to what is in fact ideally pos-
sible, would be expected to react nega-
tively to the physician whose “ideal”
has gradually descended to what is
“possible”.
The empowered health consumers’
expectation of the physician and of this
fundamental relationship is extraordi-
narily high. Met with an unresponsive
physician, patients are left to logically
acknowledge the presence of one of two
realities. Either my physician doesn’t
care about me or my physician is pow-
erless to advocate for me. Either way,
the common result is to draw the
patient away from the relationship as
he/she acknowledges “I now must fend
for myself,” and to draw the physician
away from the relationship mired in
helplessness and hopelessness. The net
effect is that patients and physicians
who are natural allies, are gradually
repositioned as adversaries. The physi-
cian is redefined as a protector or agent
of the state and the patient redefined as
an endless consumer of valuable
resources without regard to cost. Under
such circumstances, a health care sys-
tem may appear to be delivering care,
albeit with high levels of dissatisfaction
on the part of both patients and physi-
cians, while in fact it is receiving only a
partial return on its investment.
In contrast, designing health care sys-
tems that set well aligned and high
ideals for performance, and that set and
realistically resource well aligned and
reasonable expectations for improve-
ment, assure not only more cooperative
and appreciated care delivery by all
concerned, but also a fuller return on
investment in public support and accu-
mulated social capital12
.
SUMMARY
The patient-physician relationship is a
critical underpinning of stable societies,
second only in importance to family
relationships in all countries studied.
Over the past two decades this relation-
ship has been fundamentally trans-
formed from an authoritarian and
paternalistic physician control model to
a mutual partnership with team sup-
port of both clinical and patient educa-
tion missions. The emancipation,
empowerment and active engagement
of health consumers has reinforced
high expectations for physician per-
formance in both humanistic, access,
and advocacy dimensions. Physicians
ability to align with and aspire to meet
these expectations in support of
patients continued evolution will large-
RELATIONSHIP-BASED HEALTH CARE
13
ly define the physician’s future effec-
tiveness as a health care leader, the
future viability of this most critical rela-
tionship, and its ability to deliver on a
micro level movement toward preven-
tion and wellness and on a macro level
expansion of social capital and general
societal well being. The profile compar-
isons of six countries on four conti-
nents, each with a different approach to
health care system design and financ-
ing, demonstrate significantly different
levels of patient-physician alignment in
the scoring of ideal and actual perform-
ance of physicians on five dimensions
of humanism, and five dimensions of
access. These scorings would benefit
from future tracking. While it is not
possible to assign cause and effect, the
relationship between the structural
design, financing, and incentives of the
health delivery system and the position-
ing of patients and physicians/care-
givers as partners or adversaries, and the
resultant impact on the patient-physi-
cian relationship and public support for
its investment in health care infrastruc-
ture warrants further study.
Author Affiliations: Senior Fellow in
the Humanities, World Medical
Association; Director, Pfizer Medical
Humanities Initiative; Honorary Master
Scholar, New York University School of
Medicine; Professor of Surgery, Jefferson
Medical College.
Financial Disclosures: Dr. Magee is
employed as Director of the Pfizer
Medical Humanities Initiative.
Funding/Support: This study was sup-
ported by an unrestricted grant from
Pfizer Inc, New York, NY.
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