The patient-clinician relationship

The relationship between physicians and patients is fundamental to the course of treatment. The essential prerequisite for a positive relationship is effective communication. Communication enables the exchange of information, ideas, and emotions and forms the foundation of diagnosis, treatment, and care. Effective clinician–patient communication fosters trust, empathy, and shared decision-making, directly influencing patient satisfaction, adherence, and outcomes. It includes both verbal and nonverbal elements and often occurs within an asymmetric structure shaped by differences in knowledge, social status, and cultural background.

Both parties must be aware of the expectations linked to their respective social roles. The clinician’s role emphasizes professionalism, neutrality, and responsibility, whereas the patient’s role reflects individual perceptions and coping with illness. When these expectations conflict—such as balancing optimal patient care with economic constraints—role conflicts may arise.

Patients’ perceptions and interpretations of their illness, described by subjective illness theory and attribution theory, influence their behavior and cooperation during treatment. For example, beliefs about the causes or benefits of illness (primary or secondary gain) can shape adherence and engagement. Modern medicine favors the partnership model of the clinician–patient relationship, which prioritizes collaboration, mutual understanding, and shared responsibility over paternalistic approaches.

Communication allows individuals to exchange ideas, knowledge, and feelings, while also serving to build and maintain social relationships. In the medical context, communication is not only a means of information transfer but also a core element of diagnosis, treatment, and patient care. Effective patient-clinician communication fosters trust, supports shared decision-making, and significantly influences patient satisfaction, adherence, and health outcomes.

Forms of communication

• Verbal communication: the exchange of information via language (oral or written)
  • Primary functions
    • Convey explicit content, ideas, and information
    • Enable reasoning, instruction, and abstract discussion
• Nonverbal communication: the transmission of information without the use of language (through body language, facial expressions, gestures, posture, and eye contact)
  • Primary functions
    • Express emotions
    • Express interpersonal attitudes
    • Support verbal communication
    • Present one's personality
    • Conduct rituals (e.g., greetings)
• Paraverbal communication: the vocal elements accompanying speech (e.g., tone, pitch, volume, and pace)
  • Function: modulate meaning and emotional tone
• Personal communication: participants are directly opposite each other
• Media communication: participants communicate via a medium (e.g., phone or email)
• Metacommunication: communication about communication, which provides context for how to interpret a message
• Paradoxical communication: a single message containing contradictory verbal and nonverbal cues
  • Double bind: a persistent pattern of paradoxical communication in a dependent relationship (e.g., parent-child), in which the dependent person receives contradictory messages and cannot respond appropriately without violating one of them

Structures of communication

• Symmetrical communication: occurs when participants are at the same level of power and status
• Asymmetrical communication: occurs when participants are at different levels of power or status
  • Causes
    • Different social status
    • Different knowledge levels regarding the conversation topic
    • Different power dynamics
      • Definitional power: the authority to define the situation
      • Control power: the authority to decide on future actions
  • Features (evasive strategies)
    • Ignoring questions
    • Change of addressee
    • Change of topic
    • Relationship comment
    • Communicating functional uncertainty

The physician’s higher professional status often leads to asymmetrical communication.

Interaction contingency

Interaction contingency in communication refers to the extent to which communication partners follow their intended behavioral plans while mutually adjusting their actions to each other, each response depending on and influencing the other in an ongoing feedback loop. The four forms of interaction contingency provide clues about the symmetry in a communication.

Social interaction

Social status

Differences in social status shape social interactions, power dynamics, and communication patterns.

Impression management

Impression management, or self-presentation, is the process by which individuals consciously control or influence how others perceive them. Examples include:

• Self-disclosure: sharing personal information to establish identity or credibility
• Managing appearances: shaping impressions through appearance or behavior
• Ingratiation: using politeness or empathy to gain rapport

Dramaturgical theory

According to Erving Goffman, social interaction can be viewed as a theatrical performance in which individuals adjust their behavior based on the social "stage":

• Front-stage self: the public persona shown when being observed, conforming to social norms to create a desired impression
• Back-stage self: the private self expressed when the audience is absent, allowing relaxation and authenticity

Patient-clinician communication

Nondirective and directive interviewing

• Non-directive interviewing (patient-centered): the course of the conversation is guided by the patient; the physician refrains from steering it in a specific direction
  • When to use: beneficial to capture the history of present illness (HPI) in the patient’s own words at the beginning and for assessing "ICE" (ideas, concerns, expectations) at the end of history taking
  • Question style: open-ended questions ("Tell me about...")
• Directive interviewing (clinician-centered): The clinician actively guides the conversation, directing it toward specific topics or goals.
  • When to use: especially during review of systems (ROS) and the physical exam to obtain targeted diagnostic information
  • Question style: closed-ended questions/binary questions ("Yes/No")

Core principles of effective interviewing

The physician’s interviewing style plays a crucial role in shaping the patient-clinician relationship. The first three features listed below are based on the principles of Carl Rogers’ client-centered, nondirective therapy, while the fourth—transparency—reflects an important extension in the medical context. Transparency enables patients to understand the physician’s reasoning, thereby fostering trust and cooperation.

• Empathy: The physician strives to understand the patient’s perspective and accurately reflect their feelings.
• Appreciation: The physician communicates respect, acceptance, and genuine regard for the patient as a person.
• Authenticity/congruence: The physician’s verbal and nonverbal behavior are consistent; they stand behind their statements and act sincerely.
• Transparency: The physician explains the rationale for questions, diagnostic steps, and therapeutic recommendations to promote comprehension and collaboration.

The BATHE technique

A concise, structured psychosocial intervention designed for medical interviews that elicits and addresses the patient's broader context and emotional state, ultimately enhancing patient satisfaction.

• Background: "What is going on in your life?"
• Affect: "How is that affecting you?" or "How do you feel about that?"
• Trouble: "What troubles you the most about this situation?"
• Handling: "How are you handling that?"
• Empathy: "That sounds very difficult."

The Calgary-Cambridge guide

• A framework for facilitating effective communication in medical interviews; provides a structured approach to enhance the interaction between healthcare professionals and patients, leading to better clinical outcomes
• Key components include:
  • Initiating: establishing rapport and identifying the reason for the visit
  • Gathering information: using open-ended questions and active listening
  • Building relationship: using non-verbal communication and empathy
  • Explanation and planning: shared decision-making

Sociocultural difficulties

One of the most significant sociocultural challenges in patient-clinician communication arises from differences in language style, which can hinder mutual understanding. Physicians’ language use can be considered on two main levels:

• Technical vs. everyday language
  • Medical terminology is often difficult for laypersons to understand and should therefore be translated into clear, everyday language during patient interactions.
• Restricted vs. elaborated language codes
  • According to the Bernstein hypothesis, social background influences vocabulary, sentence structure, and expression.
    • Individuals from lower educational or socioeconomic backgrounds tend to use a restricted language code, characterized by simpler structure and context-dependent meaning.
    • Individuals from higher educational backgrounds more often use an elaborated language code, marked by explicitness and complex sentence structure.
  • The physician should adapt their communication style to the patient’s language code to ensure clarity and mutual understanding.

For more details, see "Key principles of communication and counseling" in the "Patient communication and counseling" article.

Problematic patient-clinician interaction patterns

Various problematic interaction patterns can negatively affect the patient-clinician relationship and the course of treatment.

• Iatrogenic fixation: A patient’s belief in having a physical illness is unintentionally reinforced by the physician’s behavior or diagnostic approach. This reinforcement can even lead to somatic symptom disorder.
• Reactance (psychology): a motivational resistance against perceived attempts to restrict one’s freedom of action or autonomy
  • To de-escalate reactance, clinicians should avoid power struggles by explicitly acknowledging the patient’s autonomy, thereby shifting the dynamic from a perceived threat to a collaborative partnership.
• Collusion (psychology): an unconscious, mutually reinforcing interaction pattern in which both parties share unrealistic assumptions or avoidance tendencies that prevent problem resolution ("The conspiracy of silence"); results in a lack of informed consent
• Projection (psychiatry): unacknowledged traits, emotions, or conflicts in oneself are attributed to another person.
• Transference (patient → physician)
  • The patient redirects emotions, expectations, or conflicts from a significant past relationship onto the physician.
  • Risks: e.g., non-compliance, inappropriate attachments or expectations towards the physician
  • Opportunity: valuable diagnostic window into the patient’s internal world
  • Example: A patient expresses intense anger towards an older female doctor because she evokes memories of his controlling mother, illustrating how past relationships influence current perceptions and behaviors.
• Countertransference (physician → patient)
  • The physician redirects emotions, expectations, or conflicts from a significant past relationship onto the patient.
  • Risk: loss of objectivity and impaired clinical judgment, leading to biased or suboptimal care
  • Opportunity: can act as an alert for the clinician to reassess their feelings, engaging in self-reflection or seeking supervision to regain professional objectivity
  • Example: A physician, influenced by a childhood marked by an emotionally distant, substance-abusing father, may feel an irrational surge of anger and become disengaged when a patient misses a follow-up appointment due to a drug relapse, highlighting the need for awareness and management of personal feelings in clinical interactions.

Transference can distort the therapeutic relationship by causing patients to react to their clinician with irrational hostility, idealization, or boundary-testing based on past relational patterns. When recognized, these emotional redirections serve as a valuable diagnostic window into the patient's internal conflicts, but if ignored, they risk inducing countertransference and compromising objective care.

Preventing iatrogenic fixation (validation without over-investigation)
To mitigate iatrogenic fixation in somatic symptom disorder, the physician must first provide empathetic validation of the patient's suffering to maintain the therapeutic alliance. The clinical focus should shift from repetitive diagnostic "rule-outs" to explaining the biopsychosocial links between psychological stressors and physiological sensations, emphasizing that symptoms are real but not life-threatening. Crucially, the physician should implement regularly scheduled, brief follow-ups that occur regardless of symptom severity. This strategy prevents contingent reinforcement, effectively decoupling the "sick role" from medical attention and refocusing the treatment goal on functional improvement rather than total symptom eradication.

Paternalistic model (traditional model)

• Core assumption: The physician knows what is best for the patient.
• Roles
  • The physician acts as a guardian, determining the course of action and assuming responsibility for the patient's welfare.
  • The patient's role is passive compliance.
• Patient autonomy: minimal; not actively involved in decision-making
• Appropriate use: This model is now reserved for exceptional cases, such as medical emergencies or when the patient lacks decision-making capacity (e.g., unconsciousness, acute psychosis).

Informative model (consumer model)

• Core assumption: The patient has clear preferences and is the sole decision-maker.
• Roles
  • The physician acts as a technical expert, providing all factual medical information and outlining available options.
  • The patient independently decides on a course of action.
• Patient autonomy: Maximum; the physician is an expert consultant, not a co-decision-maker.

Partnership model (shared-decision making)

• Core assumption: The best decision integrates medical expertise with the patient’s personal values and preferences.
• Roles: The physician and patient collaborate to develop an action plan.
  • The physician provides expert recommendations and ensures the patient understands the options.
  • The patient shares personal priorities and makes the final, informed decision.
• Patient autonomy: shared and empowered; the patient is given the information and standing to participate, which fosters the competence to manage their illness independently (self-management).
• Appropriate use: This is the preferred model in modern medicine.

Studies show that most patients have a high need for information, but their desired level of participation varies; physicians should therefore ask each patient how involved they wish to be in decisions.

Patient education
Patient education takes place during almost every clinical encounter and is fundamental to building a trusting and cooperative patient-clinician relationship. Physicians have a legal and ethical duty to inform patients about the diagnosis, necessary diagnostic procedures, expected course of the disease, and available treatment options.
If the patient’s informed consent is required—for example, before a medical procedure—this consent must be documented in writing. The following principles should be applied in the context of patient education: allow sufficient time for explanation and discussion, adapt information to the patient’s prior knowledge and individual need for information, encourage questions and emotional expression, convey realistic reassurance and hope, and ask the patient to summarize the information to confirm understanding.

Overview

• Role: a set of expected behaviors, obligations, and norms associated with a specific position within a group or social setting
• Role theory: states that human behavior is largely guided by the social expectations associated with the different positions an individual holds in society
• Role conflict: the tension experienced when the expectations or demands of two or more different social roles held by the same person are incompatible
• Role strain: the tension experienced when the competing demands or expectations within a single role become difficult to manage
• Role exit: the process of disengaging from a social role
• Role deviation: behavior that differs from the norms and expectations associated with a particular social role
• Role distance: the act of intentionally separating one's self-identity from a role, often to show that the role does not fully define them
• Role identification: the process by which an individual internalizes and adopts the expectations, values, and behaviors associated with their social role
• Role conformity: adhering to the norms and expectations attached to a social role
• Social sanction: a positive or negative reaction to a role expectation, encouraging conformity to social norms

Norms of the clinician role

Like any social role, the clinician's role is associated with specific expectations and norms. The American sociologist Talcott Parsons (1951) identified the following key expectations for the medical profession:

• Functional specificity
  • Intervenes only within the boundaries defined by professional duties and expertise
  • Does not act beyond their own field of competence or outside the medical profession
  • Uses professional authority responsibly and does not exploit the patient’s trust
• Affective neutrality
  • Maintains professional distance and objectivity by setting aside personal emotions toward patients
  • Essential for interacting appropriately with patients who may elicit discomfort, frustration, or excessive sympathy
• Universalism
  • Treats all patients equally, regardless of factors such as age, gender, ethnicity, religion, or social background
  • Bases medical decisions solely on professional and ethical standards.
• Collective orientation (altruism)
  • Acts primarily in the interest of patients and the broader public good, placing personal benefit or financial gain secondary
• Competence
  • Applies medical knowledge and skills responsibly within the scope of professional tasks (diagnosis, therapy, prevention).
  • Commits to continuous learning and maintaining professional standards

Stressors in the medical profession

The unique demands of the medical profession can give rise to a range of psychological and physical stressors. In addition, clinicians may experience role conflicts.

Helper syndrome
Many individuals in social (helping) professions are driven by a need to support others, which provides a sense of strength. However, this intense focus can result in them overlooking their own need for help, potentially leading to burnout.

Support services for health care professionals

To cope with professional difficulties, health care professionals can use services like supervision and Balint groups.

• Supervision
  • Definition: a formal process of individual or group counseling led by a trained supervisor
  • Goal: reflect on and improve the overall effectiveness of one's work, such as enhancing diagnostic skills, refining therapeutic approaches, and managing professional stress
• Balint group
  • Definition: a group discussion led by a trained facilitator in which health care professionals analyze problematic cases to find solutions
  • Goal: specifically focus on and improve the patient-clinician relationship by exploring its underlying psychological and emotional dynamics

The "sick role"

The American sociologist Talcott Parsons defined the key features of the "sick role". A major criticism of Parsons’ sick role theory is that it reflects an outdated, one-sided, and physician-centered view of illness that overlooks chronic diseases, patient autonomy, and the social diversity of health experiences.

• Exemption from normal social obligations: Individuals who are ill are temporarily released from their usual social and occupational responsibilities (e.g., work or household duties).
• Lack of responsibility for the condition: The sick person is not held morally accountable for being ill and is not blamed for their condition.
• Obligation to seek recovery: Society expects sick individuals to want to get well and to make active efforts to recover so they can resume their normal roles.
• Obligation to cooperate with medical authority: Society expects the sick to seek competent medical care and to comply with physicians’ advice and treatment.

Perception and management of illness

Illness experience

• Definition: an individual’s subjective perception, interpretation, and emotional response to being ill
• Stands in contrast to the objective concept of disease, which describes the medical condition itself
• Shaped by psychological, social, and cultural factors that influence how illness is perceived, expressed, and managed

Subjective illness theory

Patients often develop their own explanations for the causes and meaning of their symptoms or illness, referred to as subjective illness theories. Such data are typically collected retrospectively and are not scientifically reliable, as they do not allow causal inferences. Nonetheless, understanding patients’ subjective illness theories is crucial for physicians, as these beliefs can strongly influence coping behavior, emotional adjustment, and the overall course of illness. Physicians should actively inquire about and discuss these perspectives with patients. The following levels are particularly relevant:

• Willingness to cooperate: Patients are more likely to follow medical advice if the recommendations align with their personal understanding of the illness.
• Emotional state: If a patient believes they are partly to blame for their illness or views it as punishment, this can significantly affect their emotional well-being and hinder recovery.
• Professional reintegration: A patient’s own assessment of their prognosis strongly influences whether and how they return to work after recovery.

Attribution theory

Attribution theory explains how individuals interpret the causes of behavior and events (e.g., symptoms). The causes can be divided into different dimensions.

Influence of causal attributions on the course of illness
The perception of causal factors influences the solutions an individual envisions for their illness. Thus, the type of causal attribution shapes the person’s subjective illness theory. When individuals attribute their illness to internal, controllable causes, they often feel a greater sense of self-efficacy over its course. For example, a patient who has smoked heavily for many years and then suffers a heart attack may recognize their nicotine use as a contributing factor (internal locus of control) and believe they can positively influence their recovery by quitting smoking. However, attributing negative events to oneself can also have detrimental effects. A patient who develops a brain tumor, for instance, may experience unnecessary guilt or distress if she interprets the disease as a stable, internal attribution such as punishment for a personal wrongdoing.

Depression
Depressed individuals typically exhibit an internal–global–stable pattern of causal attribution, known as a depressive attributional style. They attribute failures to causes that lie within themselves (internal locus of control for negative events), that extend across many areas of life (global), and that are perceived as unchangeable (stable). This mindset is a hallmark of learned helplessness, often reflected in thoughts such as, “I am a failure in every area of my life, and nothing will ever change.”

Biases and attribution errors

Individuals often exhibit biases and systematic errors when interpreting the causes of their own behavior or the behavior of others.

• Fundamental attribution error
  • Definition: the tendency to overestimate internal factors (e.g., personal characteristics) and underestimate external or situational factors when explaining the behavior of others
  • Example: One assumes that a classmate is lazy because they missed a deadline, without considering that they were ill.
• Actor-observer bias
  • Definition: the tendency for individuals acting in a situation to attribute the causes of their behavior to external factors, but for observers to attribute the same behavior to internal factors
  • Example: “I was late because of traffic, but she was late because she’s disorganized.”
• Self-serving bias
  • Definition: the tendency to attribute successes to internal factors and failures to external factors, protecting self-esteem
  • Example: “I did well on the exam because I’m smart,” but “I failed because the test was unfair.”
• Optimism bias
  • Definition: the belief that negative events are less likely to happen to oneself than to others
  • Example: “Other people might get skin cancer from tanning, but I won’t.”
• Just-world hypothesis
  • Definition: the assumption that people get what they deserve and deserve what they get, implying the world is fair
  • Example: believing that someone who suffers misfortune must have done something to cause it

Influence of culture on attribution
In Western individualist cultures, people tend to explain behavior by focusing on internal or dispositional factors, such as personality or personal choices. They therefore are more prone to the fundamental attribution error and the self-serving bias. In contrast, collectivist cultures more often attribute behavior to external or situational factors, such as social context, community, or group relationships.

Factors influencing the perception of others

• Environmental context
  • Situation and surroundings strongly affect how behavior is interpreted.
  • Example: In a busy emergency room, a stressed physician may perceive an anxious patient as “difficult,” whereas in a calm setting, the same behavior might be recognized as fear or pain.
• Self-perception
  • Individuals view others through the lens of their own experiences, emotions, and attitudes, which can enhance empathy but may also lead to bias or misjudgment.
  • Example: A physician who has personally experienced chronic pain may show more understanding toward a patient with similar complaints, while another might underestimate the severity if they have never faced such symptoms.
• In-group vs. out-group dynamics
  • Individuals tend to favor others who share their background, culture, or profession (in-group) and may unconsciously stereotype or distance themselves from those perceived as different (out-group).
  • Example: A clinician might communicate more openly with a colleague from the same cultural background but unintentionally use less patient-centered communication with someone from a different culture or socioeconomic group.

Locus of control

• Definition: an individual’s general belief about the extent to which life outcomes are determined by their own actions versus factors beyond their personal influence. In the context of health and illness, it reflects who or what patients believe can influence their symptoms and the course of the disease.
  • Internal locus of control: patient believes they can influence the symptoms and the course of the illness themselves
  • Social-external locus of control: patient believes others (e.g., physicians) can influence the symptoms and the course of the illness
  • External-fatalistic locus of control: patient believes abstract factors like fate or chance determine the symptoms and the course of the illness

Illness gain

• Definition: the psychological or social advantages a person may obtain from being ill, such as increased attention, care, or relief from responsibilities
  • Primary gain: the internal/psychological advantages obtained as a result of being ill
    • E.g., sympathy, attention, feeling less guilty because one is sick
  • Secondary gain: the external/tangible advantages obtained as a result of being ill
    • E.g., financial compensation, warm meals while hospitalized, not having to go to work
  • Tertiary gain: benefit to a third party
    • E.g., a caregiver getting attention

Illness coping

• Definition: the cognitive, emotional, and behavioral strategies individuals use to manage the demands of illness
  • Action-related coping: active behavioral strategies, e.g., engaging in constructive activities or temporary social withdrawal
    • Endurance behavior: an active behavioral strategy where the patient ignores physiological signals (pain) to maintain normal functioning; while it seems "productive," it can lead to physical overuse, lack of recovery, and potential worsening of the underlying condition
    • Avoidance behavior: physical and/or social activities are avoided due to the fear that activity will cause injury or increase pain (fear-avoidance strategy) → physical deconditioning, social isolation, and long-term disability
  • Cognition-related coping: cognitive strategies, e.g., problem analysis or acceptance of the situation
  • Emotion-related coping: emotional regulation strategies, e.g., maintaining optimism or experiencing resignation

Treatment adherence

See "Treatment adherence" in the "Managing chronic conditions" article.

Symptom expression

Individuals may consciously alter the expression or reporting of symptoms.

• Simulation: deliberate feigning or fabrication of symptoms that do not actually exist
• Dissimulation: conscious minimization, concealment, or denial of existing symptoms
• Aggravation: deliberate exaggeration of real symptoms, portraying them as more severe than they are