Effect of COVID-19 on doctor-patient relationship

INTRODUCTION

There are few relationships as sacrosanct as the one between a doctor and a patient. It is built on trust, communication, mutual respect and empathy and influenced by the practice of medicine, ethics and the law. However, all these have been disrupted by the present COVID-19 pandemic. Patients are physically and emotionally separated from their doctors due to use of PPE, telemedicine and patients fear of accessing healthcare.¹

Over the years, changing patterns in the society, advances in the medical care and easy access to medical information has made the doctor-patient relationship challenging.^2-4 The famous Canadian physician, Sir William Osler, stated, “A good physician treats the disease and a great physician treats the patient who has the disease”.⁵ This is a crucial note to keep in mind when it comes to managing patients. To provide the patient with high quality care, there needs to be a healthy doctor-patient relationship. Communication and trust are the key elements among the other factors in building a healthy relationship.^6,7 Effective communication has always been one of the ingredients of success in all fields of work. Having good communication skills is considered a ladder to success whether in the field of economy or medicine.

In health care settings, trust and communication are labeled a tool for better patient care and patient satisfaction. There is a necessity to have some degree of trust to build a climate in which honest communication can flourish. Effective and efficient communication is a predictor of medical practice and delivery of health care services.^2,8 The quality of interaction with the patients is positively related to trust and patient satisfaction. All of these are either direct or indirect measures of the quality of health care services.^9-13

It is hoped that physicians have two types of relational skills, namely: instrumental, or the conducts related to the task, and socio-emotional conduct. In the first, questions are made and information is provided; while in the latter, feelings are addressed and empathy and commitment are shown. Affective communication between physicians and their patients is characterized by a balance between instrumental conducts and affective conducts, depending on the patient’s specific needs.¹⁴ In recent times, a great deal of factors has been found impacting on the physician-patient communication.

When it comes to ethics of the doctor-patient relationship, we see the interests of our patient as paramount, yet in this time of COVID-19 many may have received less care due to constraints, or even no care at all, as many have kept away from their doctors and hospitals. This is a double edged problem where both the doctor and the patient are keeping distances instead of breaching it. Patients have been physically and emotionally separated from doctors by PPE, remote consulting, and fear of accessing healthcare at all, which has strained the trust and communication on which the doctor-patient relationship is built.¹ The objective of the study was to assess the effect of COVID-19 on doctor-patient relationship.

METHODS

The study was a cross-sectional study conducted in a tertiary health facility in Enugu State South-East Nigeria.

Study population

The study involved all the doctors working at the Enugu State University Teaching Hospital (ESUTH) Parklane, Enugu and patients attending the General Out-Patient Department (GOPD) of the hospital. There were about 204 doctors working in the hospital as at the time of data collection however, 186 participated in the study. The patients that participated in the study were chosen by convenient sampling.

Data collection

Data was collected for a period of 4 weeks; June 2020. A structured on line (Google form) questionnaire was used to collect the data. It was shared through the different doctor’s online platforms. Data from patients attending the general out-patient clinic of the hospital were collected using a similarly structured self-administered questionnaire that was shared to consenting patients by research assistants after consultation with their doctors. The questionnaires had 2 sections, one on the socio-demographic characteristics and the second on the doctor-patient relationship.

Data analysis

The data was edited manually to detect omissions. It was analyzed with SPSS version 25. The categorical variables were shown as frequencies and percentages while the significance level was placed at p<0.05.

RESULTS

The response rate for the study was 91.2%. Table 1 shows the socio-demographic characteristics of the doctors. About half of the doctors 92 (49.5%) were in the 40-49 year age group. Majority were males 112 (60.2) and married 140 (75.3%). Half of the respondents 93 (50.0%) have worked for 11-20 years.

Table 2 shows the socio-demographic characteristics of the patients. Slightly above half 80 (51.6%) of the patients were aged 30-39 years. Majority were females 106 (68.4%) and married 88 (56.8%). Almost all the patients were Igbos 143 (91.6%) and practice Christianity 143 (91.6%).

Table 3 shows the doctor-patient relationship as reported by the doctors. Majority of the doctors reported that they still take time to listen 166 (89.2%) and talk to their patients 146 (78.5%), give their patient time to make informed decision concerning their treatment 145 (78.0%) and show empathy to their patients 166 (89.2%). However, only 22 (11.8%) of the doctors still do thorough physical examination on their patients. Majority of the doctors still take time to investigate their patients 155 (83.3%) and get feedback from them 134 (72.0%). More than half of the doctors 98 (52.7%) believe that the social distancing practice have affected their relationship with their patients while almost half of them 88 (47.3%) agree that they intentionally prolong patient’s appointment time in order to keep them away for a longer period of time. Majority of the doctors 131 (70.4%) agree that some of their patients intentionally missed their appointment for fear of COVID-19 while about half 95 (51.1%) have had cases where their patients prefers to discuss their health condition on phone instead of seeing the doctor physically. However, majority 166 (89.2%) asserted that their patients still believe in them.

Table 4 shows the doctor-patient relationship as reported by the patients. Minor proportion of the patients agree that their doctor still take time to listen 62 (40.0%) and talk 49 (31.6%) to them. However, majority 106 (68.4%) agree that they are still given time to make informed decision concerning their care. Minor proportion also agree that their doctors still show empathy 67 (43.2%) and do through physical examination 18 (11.6) on them. Majority agree that their doctor still takes time to investigate 111 (71.6%) and get feedback 93 (60.0%) from them. Almost all the patients 142 (91.6%) believe that the social distancing practice have affected their relationship with their doctors while majority 106 (68.4%) believe that their doctor have intentionally prolonged their appointment to keep them away for longer periods. Majority 106 (68.4%) also agreed to have intentionally missed their appointments 106 (68.4%) and prefers to speak to their doctor on phone 93 (60.0%) instead of physical contact for fear of COVID-19. However, majority 124 (80.0%) still believe in their doctors.

DISCUSSION

The doctor-patient relationship is built on communication between the doctor and the patient. This communication comes in form of medical interview which gives way for proper diagnosis and treatment. This communication can be verbal or non-verbal.¹⁵ The effectiveness of this communication can make or mare the doctor-patient relationship. In this study majority of the doctors asserted that even in this COVID-19 era that they still take time to listen and talk to their patients. However the assertion by the patients differ as only a minor proportion agree that their doctors still take time to listen and talk to them in this era of COVID-19. This observed difference is worrisome and shows that there is a breach in the communication aspect of the doctor-patient relationship. Without effective communication trust cannot be built and it is this trust that determines to a large extent the treatment outcomes. Studies have shown that the quality of treatment relationship is found to shape patient outcomes more strongly than the specific techniques applied.¹⁶

Majority of the doctors agree that they give their patients time to make informed decision concerning their care. This the patients concurred with. Informed decision making is paramount to effective treatment outcome.¹⁷ Increasing data suggest that patients activated in the medical encounter to ask questions and to participate in their care do better biologically, in quality of life, and have higher satisfaction.¹⁷

Majority of the doctors asserted that they still take time to have eye contact with their patients (72.0%) and show empathy (89.2%) but the patients response differ as only about half of them 88 (56.8%) agree that their doctors still have eye contact with them while a minor proportion (43.2%) agree that their doctors still show them empathy. This shows a gap in the non-verbal aspect of the doctor-patient communication. Studies have shown that in primary care, knowing the patient is at least as important as knowing the disease, and physicians with a warm and friendly style are more effective than physicians with a more formal style.^18,19 In particular, patient satisfaction, treatment adherence, and treatment outcome have been found to be associated with the doctor-patient relationship.^17,20,21 Empathy has been described as the key feature in all relationships.^22,23

For example, a patient who does not trust or like the practitioner will not disclose complete information efficiently and a patient who is anxious will not comprehend information clearly. The relationship therefore directly determines the quality and completeness of information elicited and understood. It is the major influence on doctor and patient satisfaction and thereby contributes to practice maintenance and prevention of doctor burnout, and is the major determinant of compliance.²⁴

A very minor proportion of the doctors agree that they still do thorough physical examination on their patients 11.8% and this was collaborated by the patients 11.6%. This shows the gap created by the COVID-19 pandemic. Physical examination creates bond and trust between the doctor and the patient and helps in diagnosis. Study have shown that 10% of diagnosis can be made with physical examination.²⁵

Further, many physicians still believe that the physical examination provides the doctor and the patient with an opportunity to communicate with one another, which reduces patient anxiety and can produce a “healing” effect. In fact, Phoon argues that a physical examination, “is still part of the doctor-patient relationship and still desired by patients, in spite of technological advances”.²⁶

Several studies have explored the expectations patients have in regard to their consultation with a physician and found that many expect to be physically examined by their doctor. A study reported that overall visit-specific satisfaction was positively related to the time doctors spent on the physical examination, concluding that patients were more satisfied with medical visits in which they were physically examined.²⁷ Majority of the doctors still thoroughly investigate their patients and this was agreed to by the patients. Medical investigations have been shown to also help to arrive at diagnosis in about 10% of cases. However, advances in investigative procedure have contributed to creating distance between the doctor and the patient. Hence it is not surprising that in this era of COVID-19 where many doctors shy away from physical examination that there is high rate of investigations.

About 64.0% of the doctors reported to still bother about their patients satisfaction with their consultation while only 33.5% of patients agree to this. Patient satisfaction with the doctor have been shown to affect compliance to medications and use of health facilities.²⁸

About half of the doctors 98 (52.7%) agreed that the present social distancing practice have affected their relationship with their patients while almost all the patients 142 (91.6%) asserted that the social distancing have affected their relationship with their doctors. This is not surprising as the increase in the use of PPEs both by the doctors and their patients make it difficult for good emotional and non-verbal communication between the doctors and their patients and this has been shown to create a gap in doctor-patient relationship.²⁴

About 68.4% of the patients believe that their doctors intentionally prolong their appointment time in other to keep them away for longer periods. Also about the same proportion of patients also agree that they intentionally missed their appointments in this era of COVID-19. Both the prolongation of appointment by the doctors and the misses by the patients were all for fear of being infected with COVID-19. This long gap in contact between the doctor and the patient further deepens the gap in the doctor-patient relationship and deprives the patient of the benefits of routine check-ups especially for patients with chronic diseases. The more frequent a patient sees the doctor the better their understanding of each other.

The doctor-patient relationship has its placebo effect and the probabilities of success of interventions are directly proportional to the quality of this relationship.²⁹ Higher proportion of the doctor’s trust that their patients still believe in them and a similar proportion of the patients also asserted that they still believe in their doctor. This shows that even though the present COVID-19 pandemic have affected certain aspects of the doctor-patient relationship, the patients still believe in their doctors. This may show an understanding on the part of the patients that the change in the doctor’s attitude was not meant for harm but for the good of both the patient, the doctor and the community at large.

CONCLUSION

The present COVID-19 pandemic have impacted negatively on certain aspects of the doctor-patient relationship which may on the long run influence treatment outcomes especially as the pandemic is still ongoing.

ACKNOWLEDGEMENTS

The authors acknowledge all the doctors and patients who participated in the study. They also acknowledge the research assistants who helped to collect data from the patients.

Funding: No funding sources

Conflict of interest: None declared

Ethical approval: The study was approved by the Institutional Ethics Committee

REFERENCES

1. 1. Pallavi B. Has COVID-19 pandemic changed the doctor-patient relationship forever? BMJ. 2020;367:m2221.
2. 2. Levy S. How has the physician-patient relationship changed? Medscape. 2017.
3. 3. Gerber BS, Eiser AR. The patient-physician relationship in the internet age: Future prospects and the research agenda. J Med Internet Res. 2001;3:15.
4. 4. Agarwal AK, Murinson BB. New dimensions in patient-physician interaction: values, autonomy, and medical information in the patient-centered clinical encounter. Rambam Maimonides Med J. 2012;3:17.
5. 5. Centor RM. To be a great physician, you must understand the whole story. Med Gen Med. 2007;9:59.
6. 6. Chandra S, Mohammadnezhad M, Ward P. Trust and communication in a Doctor-Patient Relationship: A Literature Review. J Healthc Commun. 2018;3(3):36.
7. 7. Mckinstry B, Ashcroft R, Car J, Freeman G, Sheikh A. Interventions for improving patients’ trust in doctors and groups of doctors. Cochrane Database Syst Rev. 2006;3:CD004134.
8. 8. Ha JF, Longnecker N. Doctor-patient communication: A review. Ochsner J. 2010;10:38-43.
9. 9. Birkhäuer J, Gaab J, Kossowsky J, Hasler S, Krummenacher P. Trust in the health care professional and health outcome: A meta-analysis. PLoS One. 2017;12:e0170988.
10. 10. Anhang-Price R, Elliott MN, Zaslavsky AM, Hays RD, Lehrman WG. Examining the role of patient experience surveys in measuring health care quality. Med Care Res Rev. 2014;71:522-54.
11. 11. Tsai TC, Orav EJ, Jha AK. Patient satisfaction and quality of surgical care in US hospitals. Ann Surg. 2015;261:2-8.
12. 12. Isaac T, Zaslavsky AM, Cleary PD, Landon BE. The Relationship between patients’ perception of care and measures of hospital quality and safety. Health Serv Res. 2010;45:1024-40.
13. 13. Jha AK, Orav EJ, Zheng J, Epstein AM Patients’ perception of hospital care in the United States. N Engl J Med. 2010;359:1921-31.
14. 14. José HO. Evolution and changes in the physician-patient relationship. Colomb Med. 2011;42:400-5.
15. 15. Goldberg PE. The physician-patient relationship. Three psychodynamic Concepts that can be applied to primary care. Arch Fam Med. 2000;9:1164-8.
16. 16. Martin DJ, Garske JP, Davis MK. Relation of the therapeutic alliance with outcome and other variables: a meta-analytic review. J Consult Clin Psychol. 2000;68:438e50.
17. 17. Kaplan S. Patient activation. Presented at Royal College of Medicine symposium on Doctor Patient Communication, Washington, DC, 1997.
18. 18. Heath I. That by which it is what it is. Br J Gen Pract. 2009;59:142-3.
19. 19. Di Blasi Z, Harkness E, Ernst E, Georgiou A, Kleijnen J. Influence of context effects on health outcomes: a systematic review. Lancet. 2001;357:757-62.
20. 20. Fuertes JN, Mislowack A, Bennett J, Paul L, Gilbert TC, Fontan G, et al. The physician-patient working alliance. Patient Educ Couns. 2007;66:29-36.
21. 21. Griffith S. A review of the factors associated with patient compliance and the taking of prescribed medicines. Br J Gen Pract. 1990;40:114-6.
22. 22. Hojat M, Mangione S, Nasca TJ, Cohen MJM, Gonnella JS, Erdmann JB, et al. The Jefferson Scale of Physician Empathy: development and preliminary psychometric data. Educat Psychol Measure. 2001;61:349-65.
23. 23. Mercer SW, Maxwell M, Heaney D, Watt GC. The consultation and relational empathy (CARE) measure: development and preliminary validation and reliability of an empathy-based consultation process measure. Fam Pract. 2004;21:699-705.
24. 24. Lipkin M Jr, Putnam SM, Lazare A. The medical interview: clinical care, education, and research. New York, NY: Springer-Verlag; 1995:134-44.
25. 25. Pendleton D, Schofield T, Tate P, Havelock P. General approaches to the consultación. Oxford: Oxford University Press; 1992.
26. 26. Phoon CKL. Must doctors still examine patients? Perspect Biol Med. 2000;43(4):558.
27. 27. Rice T. Listening as touching, and the dangers of intimacy. Earshot. 2007;5:15-21.
28. 28. McGuire TG. Physician agency. In: Handbook of health economics. Vol. 1. Elsevier; 20001:461-536.
29. 29. Turabian JL, Pérez Franco B. The concept of treatment in family medicine: A contextualized and contextual map of a city hardly seen. Aten Primaria. 2010;42:253-4.