Changing Doctor Patient Relationship: “Hostile Dependency Syndrome”
Summary: Violence against health care providers is widely rampant and this has
contributed to increasing cost of health care and added to patients’ sufferings.
Relationship between a doctor and patient is essentially a relationship of trust and
only this kind of relationship is in the best interest of patients because of their
limited understanding of medical principles, practice and realities of the market
place. Patients’ hostile conduct towards their doctors has been described as
Hostile Dependency Syndrome.
Hostile Dependency Syndrome reflects normal dependence of patients upon their
doctors for their welfare, hostile conduct of patients towards their treating
doctors and the ensuing violent, arbitrary and illegal conduct of patients towards
Nature of doctor patient relationship has undergone a profound change during
later half of last century and particularly during the last 4 decades. Patients are
becoming increasingly hostile towards their doctors. Mass media and judicial acts
have contributed in a great measure towards increasing hostility.
For media every story involving doctor patient conflict is a hit and hot story
wherein doctor’s side of the story is often ignored and for individual controversies
of doubtful merits, entire profession is painted in black. I have rarely come across
news in which prima-facei allegations against the treating physician are made out.
Their sole motive is to sell their own publication and they know it well that such
stories are a hit among consuming masses. They are least bothered that such
biased reporting does no good to the subjects for whose cause they are
apparently fighting. This imbalanced, irresponsible reporting only increases
alienation of doctors from their patients and serves to strengthen the invisible
battle line between doctors and their subjects i.e. patients.
Judiciary relying upon its authority under law of torts has adopted the robe of
legislature and redefined doctor patient relationship from a natural relationship
based on mutual trust to a legal relationship based on contract for service. This
effectively means that a doctor is duty bound to provide all the services to a
patient on demand but all the authority vests in the patient. It includes duty to
inform and the duty to procure informed consent from the patient. It is the duty
of the doctor to educate the patient about his clinical condition and the
treatment to be undertaken to such an extent that patient is able to take prudent
and pragmatic decisions before granting his consent. Judiciary in their wisdom has
completely ignored patient’s ability to comprehend his doctor’s word. Moreover
judiciary is completely oblivious to the ability of a doctor to treat a patient upon
whom he has no authority. A doctor is legally required to protect his patient’s
interests even in those situations where patient acts arbitrarily, whimsical,
idiosyncratic and in utter disregard of his doctor’s advice. For example a doctor is
supposed to provide discharge summary even when patient leaves the hospital
contrary to medical advice.
The traditional and the natural view that doctor patient relationship is essentially
a relationship of trust , the treating doctor being the best judge of his patient’s
clinical condition and the treatment to be given, has been given a good bye.
Patients are no longer satisfied with the only right given to them i.e. right to
select their doctor. Patients no longer feel that they are duty bound to comply
with their doctor’s advice. Majority of patients in exercise of their right to
personal satisfaction think that they have a free will and no rule of conduct
applies to them but at the same time they expect a doctor to be bound by ethics,
morals, law and at the same time be able to or is rather duty bound to cater to all
their individual interests, whims, fancies, wild and weird ideas. Patient would not
hesitate to call themselves as customers and even law has recognized them as
consumers. Doctor’s legal liability towards his negligence has been blown out of
proportion. Patients often levy wild allegations and thus harass doctors before
various legal and administrative forums even when their allegations are
ambiguous and lacking in particulars of alleged negligence.
Increasing hostilities have led to alienation of doctors from their patient’s welfare
which is reflected in refusal to attend odd hour calls and majority of doctor’s
children opting for a profession other than medical profession (According to one
survey 85% of doctors children do not want to become doctors). Doctors often
agitate in pursuance of their demand for increased security. Hospitals have
employed bouncers to keep trouble mongers off. In one Indian state, many
doctors keep arms and ammunition in their clinics for the purpose of personal
Hostilities and unreasonable conduct of patients and their attendants have led to
a vicious cycle wherein doctors are progressively becoming more commercial and
manipulative whereas patients are becoming more hostile. Clinical acumen based
practice has given way to scientific and legal evidence based practice in which
instead of patient welfare, the doctor’s preoccupation is being on the right side of
law irrespective of cost of treatment to the patient. This has made healthcare
very expensive and unaffordable for the great majority. Hence in USA, these days
there is talk about Obama Care.
Nature of doctor patient relationship: It is essentially a relationship of trust. The
reason being that no human being in his capacity as patient have sufficient
knowledge and experience to be able to determine the best for him and choose
and demand accordingly. His treating doctor is the only person competent to do
by virtue of his education, cumulative experience, knowledge, skills and
management practices. It is not possible to lay down law and legal procedures to
meet vast diversity of situations any doctor encounters in his medical practice.
Therefore, for his well being patient is squarely dependent upon the treating
doctor. Under these conditions, nature of relationship demands that patients
must be modest while dealing with their doctors so as to draw maximum benefit
out of cumulative experience of the attending physician. In this situation, the only
right that can be granted to a patient is the right to select his doctor and this right
has already been granted to all the patients. But once a patient has chosen a
doctor, he is bound to comply with his doctor’s prescription in his own interest
and is bound to pay fee for services rendered. In my medical practice, I have seen
that even the most intelligent of patients are rarely in a position to control and
regulate management of their clinical condition.
Doctor’s perspective: Medical practices demand a holistic approach and require a
doctor to utilize his total experience for the benefit of each and every patient.
There are no stereotyped responses. Best medical practices have evolved over a
period of 2000 years and are beyond a patient’s common sense. A doctor
demands compliance of his prescription and fee for the services rendered.
Doctor’s only concern is clinical condition of the patient and its management. A
doctor can’t refuse treating a patient on grounds of personal enmity or likes and
interests. In the great Indian epic Ramayana, Ravana’s personal physician Sushain
was called upon to treat his opponent Laxman and Sushain never refused.
Acts of a doctor are often amenable to peer-review but no member of judiciary,
bureaucracy or legislature can ever be competent to judge a doctor’s acts or
prescribe conduct rules for doctors. To extract the best out of a doctor, a patient
has to be modest and comply with his prescription and be ready to pay fee for the
services rendered. Trust, modesty and compliance are the 3 cardinal principles for
patients to better connect with their doctors. Quite often doctors encounter
patients seeking free consultation for one or the other reason and employ all
sorts of tools and techniques to achieve their ends. But little they realize that this
is the beginning of doctor patient conflict.
Patient’s perspective: Patient often tend to think that doctors are just like any
other businessman or service provider working in accordance with profit
maximization theory of a firm. Accordingly patients don’t hesitate to regard
themselves as consumers or customers of the attending physician. Patients not
only exercise discretion in selection of their doctors but also pass all sorts of value
judgments about their doctor. They will interfere at each and every step of the
way. Patients often demand doctors to satisfy their illegitimate and illogical
interests, whims and fancies. On one hand they would elevate a doctor to the
level of God and the next moment they can be seen indulging in reckless violence
against their doctors. Patients generally have a very poor idea of medical
practices and realities of market place but want to dictate themselves under the
pretext of seeking satisfaction, at times only because they are paying the money.
Because of wide gaps in perception of doctors and patients, conflicts are
inevitable and hence “Hostile Dependency Syndrome”.
Hostilities against health care providers at all levels of social hierarchy have led to
a shift from clinical acumen based medical practice to scientific and legal evidence
based practice. In the former, for a doctor, patient’s welfare is supreme whereas
in the later being on the right side of law is the supreme consideration. The later
approach not only makes healthcare extremely expensive and unaffordable for
majority of the patients but also acts contrary to patients interests in so many
So the best approach for a patient is to establish a relationship rooted in trust so
that the attending doctor feels responsible for his patient and makes his best
efforts to restore his patient’s health. But hostile attitude, raising unreasonable
demands or indiscriminately exercising his rights and opportunities is clearly
counterproductive. I have seen patients hurting themselves more often by their
own negligence rather than negligence on the part of their doctors.
It is against this backdrop that http://curatio.in has been founded in order to help
patients in taking informed decision in the matter of selection of their health care
provider and reap the greatest benefit out of his cumulative experience. It is
sincerely expected that this initiative would improve doctor patient relationship
leading to decline in incidence and prevalence of Hostile Dependency Syndrome.
Author: Dr Mahesh C. Jain is a practicing medical doctor and has written the
book “Encounter of Science with Philosophy – A synthetic view”. The book begins
with first chapter devoted to scientifically valid concept of God and then explains
cosmic phenomena right from origin of nature and universe up to origin of life
and evolution of man. The book includes several chapters devoted to auxiliary
concepts and social sciences as corollaries to the concept of God. This is the only
book which deals with origin of nature and universe from null or Zero or nothing.