Challenging Dogma - Spring 2009

Wednesday, May 6, 2009

Doctor-Patient Interactions: A Failing Public Health Initiative in Need of Greater Social and Behavioral Science Considerations — Ben Schanker


The doctor–patient relationship has historically been a keystone of health care. Physicians have been and continue to be a predominant source of health information. For many patients, the doctor’s office remains the primary location where health information is disseminated and an effort is made to induce behavioral changes in patients. From this standpoint, doctors within a health care system can be viewed as part of a joint initiative to improve public health. Along a similar framework, doctors can be compared to personal commercials or advertisements that endorse certain health behaviors or use of specific products.

The traditional medical model is one marked by physicians as the primary authority in the treatment of illness (1). Doctor-patient relationships typically center on control and direction by physicians. Paternalism is also a common theme, in which physicians may neglect patient autonomy, and personal physician views of what is best for the patient are given higher priority, even if they conflict with patient opinions (2). Although changes in recent decades have put a greater emphasis and importance on patient control and autonomy in medical treatment, paternalism remains a prevalent theme in clinical practice. Doctors are the core manager of a patient’s illness, and the common practice is for patients to follow the “doctor’s orders”.

Yet despite the important role physicians play in ensuring public health, the traditional medical model and approach is failing. Issues with patient non-compliance in treatment regimens are common, with estimated compliance rates in the 30-60 percent range for common chronic conditions (3), and as low as 7% for others (4). U.S. health care expenditures were $2.2 trillion in 2007 (16.2% of the Gross Domestic Product) and are expected to rise to 20.3% of the GDP by 2018, with a continual 6.2% growth rate per year (5). Despite rising costs, many patients are more dissatisfied with their healthcare (6), and despite more money being spent on health care, health outcomes are not improving (7). Patients’ expectations of their doctors are increasingly unmet, medical malpractice lawsuits are on the rise (8), and financial conflicts of interest are corrupting the practice of medicine.

The nature of physician-patient relationships and clinical health care delivery are in a state of turmoil. Inefficient interactions warrant a critical analysis of current practices and approaches. Three core issues hinder the effective delivery of clinical care in doctor-patient interactions: 1. An overemphasis on the biomedical considerations of illness and a neglect of social or environmental factors, 2. Predominant use of the Health-Belief Model (HBM) in targeting behavior change, and 3. A lack of patient empowerment and self-efficacy. These issues contribute to ineffective and inefficient health care. An evaluation of these concerns illuminates necessary areas for improvement, and invokes greater consideration of social and behavioral science principles.

A predominantly biomedical model of treatment

Medical treatment is characterized by an emphasis on the natural sciences (biology, chemistry, and physics) within a predominantly biomedical model. The reliance on pharmacological drugs and biotechnological therapies is high, and these constructs are generally the preferred targets in attempts to improve health outcomes (9). Moreover, the practice of medicine is often technocratic and dehumanizing. Patients are often objectified and treated as “cases” or diseased entities rather than people with social narratives, circumstances, and backgrounds. Doctors often treat diseases, not necessarily people. Medical school and residency training focus on medical or disease history, with little or no reference to underlying social factors like socioeconomic status or environmental circumstances of patients (10).

Doctors often aim to treat the physical manifestation of disease by targeting biochemical interventions, but the underlying causes of illness may not be biomedical. Social or environmental factors may be at the root of a patient’s problems. Evidence indicates that people of lower socioeconomic status have higher morbidity and mortality with most major chronic diseases (11). Over the past several decades, simple changes in sanitation, diet, and lifestyle have had more drastic effects on improving public health than many biotechnological advances (9). In traditional perspectives and academic disciplines, social, economic, environmental, and cultural factors have largely been ignored (12), and underemphasized as determinants of health.

While physicians typically value compliance and adherence to a treatment regimen, patient values may lie elsewhere, in factors such as finances, convenience, cultural or religious beliefs, body image, or various other factors (13). For example, while a doctor may be strongly recommending chemotherapy for treatment of cancer, a patient may be reluctant to undergoing therapy due to fear of social stigmatization resulting from hair loss or other side effects (14). In addition, while a physician may prescribe an antibiotic regimen to a patient with a bacterial infection, lack of insurance or available financial resources may result in noncompliance with the doctor’s orders. These social or behavioral factors may easily be ignored by physicians that use a primarily biomedical model of treatment.

Moreover, environmental or structural components may be limiting factors that reduce patient compliance. For example, a patient in a neighborhood with few or no pharmacies may be unable to obtain antibiotics despite having a doctor’s prescription (13). These examples highlight potential underlying reasons for noncompliance. Ignoring the social, behavioral, or environmental factors may render a treatment plan ineffective. In many cases, a physician is unlikely to successfully solve the patient’s health issues if the focus is solely or primarily on biomedical causes.

An understanding of social, behavioral, and environmental factors can significantly improve a physician’s ability to treat a patient, and is therefore necessary. By understanding underlying constructs of illness, like socioeconomic status or social support, health care practitioners can target the fundamental causes of illness (15). While natural science and technology are certainly important factors in the treatment of patient ailments, the current biomedical model often fails to consider social, behavioral, and environmental factors. The issues in medicine are partly rooted in this oversight.

Predominant Use of the Health-Belief Model

The Health-Belief Model has been a paradigm in medicine and public health for several decades (16). Physicians often target the perceived susceptibility and perceived severity of illness to induce behavioral change. For example, a physician that discovers high blood pressure and cholesterol levels in his/her patient will attempt to persuade the patient to eat a healthy diet of fruits and vegetables, and exercise more frequently, by explaining the risks of heart attack, stroke, and other ill outcomes. In this manner the physician attempts to increase the patient’s perceived susceptibility to or severity of morbidity and mortality. If effective, the patient then cognitively weighs benefits of and barriers to action, creates an intention to eat a healthy diet and exercise more, and performs the behavior. Physician recommendations to patients may often act as cues to action within this Health-Belief Model construct (17). Drugs may be prescribed and an effort made to target the patient’s perceived benefits of complying with recommendations.

Yet there are many limitations to using the Health-Belief Model in clinical practice. When physicians use the Health-Belief Model, patient initiative and control are largely ignored, and interventions to promote health often fail in clinical settings (18). While the perceived susceptibility and severity might be effective targets for improving behavior short-term, long-term changes in health behavior are limited under the model. There are several instances in the literature that indicate that the perceived severity of illness is often unrelated to health behavior (19). In addition, a more recent study of Multiple Sclerosis patients found that perceived barriers also failed as a predictor of adherence to treatment regimen (20).

Moreover, health behavior is often determined by a number of factors that are not directly health related, and patients may often act irrationally, especially in scenarios of addiction (21). Interventions based on the Health-Belief Model fail to consider cultural factors, which have been shown to be significant predictors in determining patient compliance (22). Additional disregard of environmental factors may result from interventions based on the model’s principles, and use of the model has historically been oppressive in nature, especially to minorities and women (23). See in book of papers

The Health-Belief Model appeals to a core value of health, and most, if not all, physician interventions are based on this core value. Yet there are much more appealing values, such as freedom, independence, attractiveness, and others. An appeal to health status may often be an ineffective incentive in compelling patients to change behavior or comply with a doctor’s recommendations. Patients may not value health as much as physicians and some patients may even have destructive health tendencies. Physicians practicing under the Health-Belief Model are severely limited in how much they can improve patient health.

A Lack of Empowerment

Physicians have historically practiced in a paternalistic model, where decision-making lies primarily with the doctor. Patients are often persuaded to adhere to the physician’s opinions for optimal treatment. In this model of medical care, there is a significant lack of empowerment or self-efficacy. In the traditional medical model, physicians remain the controlling power in treatment of illness, and patients are more often perceived as bystanders in treatment decisions.

But, effective medical treatment and patient compliance rely on physicians being able to empower patients to control their illnesses. For example, diabetes mellitus is predominantly a self-managed disease, much like many other chronic conditions, and its management relies on patients being able to monitor and administer insulin. Similarly, antibiotic regimens often require patients to adhere to a schedule of taking pills. Many illnesses require patients to be active in health maintenance and follow-up procedures. Treatment failure and noncompliance can be repercussions of a physician not empowering or motivating patients to manage their conditions.

Many patients also reject the strength of paternalism associated with the traditional medical model of treatment, and favor a more self-managed approach (24-25). Initial studies comparing paternalistic models with patient empowerment indicated worse health outcomes in paternalistic-centered doctor-patient relationships and better compliance in models that focused on patient empowerment (1). Similarly, patient self-efficacy is crucial to ensuring that treatment protocols or regimens are followed. In various health scenarios, self-efficacy is the best predictor of improved health behavior and outcome (24). Many physicians fail to empower their patients, and the general model of medical practice needs improvements.

Summary of Issues

Health behavior is extremely complex; biochemical, social, behavioral, environmental, and cultural factors all play a role in determining an individual’s health. Yet often, many of these factors are not addressed, and the current delivery of care within doctor-patient interactions is deteriorating. The evaluation of current approaches indicates several core issues. A clinical focus on a predominantly biomedical model of disease and illness significantly limits the ability of physicians to improve the health of patients. Moreover, a reliance on Health-Belief Model principles, targeting an often unattractive core value of health, and failure to empower patients or promote self-efficacy further hinder the efficacy of physicians. The health care scene is in disarray, and issues of low patient compliance, ill health outcomes, and inefficiency of care are a testament to the inadequacy of current practices. Doctor–patient encounters are a crucial setting for interventions to improve health outcomes, and it is important to recognize the issues contributing to inefficient and ineffective health care. Physicians hold an immense potential and responsibility to benefit patients, and it would be both tragic and negligent to not address current limitations. Resolving the issues with social and behavioral science principles holds great promise in improving public health.


The many issues in doctor-patient relationships within the current troublesome health care system indicate a pressing need for medical and professional education reform. Medical students generally have four years of medical education. Physicians are also required to take continuing medical education courses as a component of retaining licensure to practice medicine. There is an increasing perception that physicians and other health care providers lack sufficient high quality information about effective patient intervention strategies when dealing with various health issues (27-28). A number of national medical education groups have noted the need for reforms in medical education to prepare students and professionals to practice better in the changing health care environment (29-33). The Institute of Medicine has specifically recognized the need for greater social and behavioral science content in medical school curricula (34).

In 1996, the AAMC embarked on the Medical School Objectives

Project, an initiative that was designed to stimulate changes in medical education to create a better alignment of the educational content and goals with evolving practice patterns (30). These changes have included a greater focus on primary care, ambulatory care, health promotion/disease prevention, teamwork, medical care cost control, and providing cost-effective care (35-39). Yet changes to increase social and behavioral science components have been minimal.

Many medical schools have insufficient inclusion of social and behavioral science education within curricula. Students are inundated with classes on anatomy, biochemistry, cell biology, endocrinology, embryology, genetics, physiology, and neuroscience, with very little to no focus on learning about behavioral and social sciences or communication skills (40). The Institute of Medicine recommends that medical students be provided with an integrated behavioral and social science curriculum that extends throughout all four years of medical school (34), but most medical schools have yet to implement this. “Social and behavioral sciences in medical education have been underemphasized and in some areas ignored,” says Jason M. Satterfield PhD, director of behavioral medicine and associate professor of clinical medicine at UCSF (41). Considering that roughly half of all deaths in the United States are linked to behavioral and social factors (42), medical students must be taught knowledge and skills within social and behavioral sciences in order to recognize, understand, and treat disease and illness. Physicians must be able to treat patients, not just symptoms, and they must understand the role of social and behavioral factors in illness etiology.

In 2001, the University of California in San Francisco (UCSF) began seriously integrating social and behavioral sciences into their medical school curriculum, and in 2006 they received a five-year, $1.25 million grant from the National Institutes of Health (NIH) to exclusively revise and integrate the social and behavioral sciences in medical education (41). While promising, this award is unprecedented. More resources and effort are needed to adequately reform medical education across the country. Greater integration of social and behavioral sciences in medical curricula is crucial to raising future physicians that can effectively improve health care delivery. A change should include more or longer courses in social and behavioral sciences, as well as an integration of social and behavioral science principles with biological sciences and clinical application.

To address many of the issues with the current doctor-patient relationship paradigm, social and behavioral science education in medical curricula or professional education should include a shift away from the predominantly biomedical model of disease, an inclusion of alternative models of health behavior change (apart from the predominantly used Health-Belief Model), and an increased emphasis on patient empowerment and self-efficacy in treating disease, with less focus on paternalism or physician control. Emphasizing these points in medical education will raise clinicians and physicians that are better apt and able to treat patients effectively. Moreover, medical students and residents should ideally have more interaction with faculty within community or home settings where patients spend the majority of time, rather than strictly in hospitals.

A Shift Away From the Predominant Biomedical Model of Treatment

Inclusion of social and behavioral sciences in medical school curricula will help physicians recognize the underlying causes of disease, which may not be biomedical but rather behavioral or social. Biological factors certainly play a role in the etiology of illness, but these factors are intricately intertwined with social, behavioral, and environmental factors (43). A strictly biomedical model limits a physician’s ability to recognize, evaluate, and implement an effective treatment plan for patients. While the biomedical model focuses more on a transient or immediate solution to solve a disease or illness problem (e.g. pharmaceutical drugs), integration of social and behavioral science principles allows physicians to treat patients longitudinally. Extensive behavioral research has shown that many health problems cannot be ultimately solved by short-term biomedical interventions, but rather require long-term behavioral change (44-46). Physicians that are educated in social and behavioral science principles will be better able to provide support and guidance to help patients sustain behavioral changes that improve health.

Moreover, medical training in patient homes or work settings, instead of hospitals, has been suggested to enhance clinician-patient interactions and improve adherence to physician recommendations (47). Evidence suggests that clinicians that actively support changes in social and environmental conditions can effectively make large-scale improvements in community health, and drastically improve individual patient health outcomes (48). Physicians that are educated in social and behavioral science principles have greater knowledge and ability to improve patient health compared to those that lack social and behavioral science education. The integration of social and behavioral science principles into clinical practice can effectively improve health care delivery and increase effective translation of science research to community health improvement (49-50).

A Shift Away From the Predominant Health-Belief Model

Greater emphases on alternative social and behavioral models of health behavior change in medical education will train more effective doctors and improve health care delivery. Models like framing theory, social learning theory, advertising theory, or marketing theory all hold great potential in improving the delivery of care. There is growing support and agreement among public health professionals for the use of these and other alternative theories, which put a greater emphasis on the role of social, environmental, or behavioral factors in illness (51). Teaching these alternative models to medical students, residents, and current physicians will empower them to improve patient health more effectively.

There is significant evidence supporting the use of framing theory to effectively improve health behavior (52-55). Doctors that are educated about framing theory are capable of sending more persuasive messages to patients; messages that will improve compliance, increase the adoption of healthy behavior, reduce risky behavior, and improve public health. Similarly, researchers have found significant merits in using social learning theory (43). Although the research on advertising theory and marketing theory is limited, mainly because of limited use in academic investigations of health behavior change, there is significant promise for using these theories based on their successful use in general marketing and advertising campaigns (56). Many of these alternative theories have principles that have been indicated to be more effective than the Health Belief Model in accurately modeling and implementing health behavior change (56). Moreover, physicians that appeal to core values like freedom, sex, attractiveness, or autonomy have the potential to drastically improve patient health, much more than those appealing to values of health.

Numerous studies have also indicated that an integration of many of the concepts and principles from various social and behavioral theories is effective in improving health behavior (56-59). Physicians that are educated about social and behavioral theories have a greater ability to integrate concepts from various social and behavioral theories to effectively improve the health of their patients. Trained physicians can assimilate biomedical principles with the social, behavioral and environmental principles from behavior-change models to create patient treatment plans that consider the numerous factors affecting illness.

Emphasizing Patient Empowerment and Self-Efficacy

Doctors that are trained to empower patients to take control of their personal treatment will be more effective in improving patient health than those that fail to empower their patients. Although the traditional perceptions of health care include passive patients that are “fixed” or “cured” by physicians (27), many of today’s chronic conditions (e.g. diabetes and obesity) require proactive lifestyle changes and self-management of illness in everyday activities over long-term periods (60). There is significant evidence to show that self-management education of chronic disease patients is effective in improving control of the disease (61, 62). Based on these results, and other studies, The Task Force on Community Preventive Services has recommended patient self-management in home and community settings (63).

Research comparing paternalistic, passive-patient models with patient empowerment concluded that models focusing on patient empowerment are more effective in improving health (1). Similarly, studies of chronic diabetes patients found that patients with health care providers that were autonomy supportive were more motivated to regulate their health, felt more empowered, and showed improved health outcomes (64). Comparable results were also found in clinical trials for smoking cessation (65). These findings suggest that physicians should be adequately trained to empower their patients and promote self-efficacy.

Physicians that are educated to focus more on empowering their patients will not only be more effective in improving patient health, but they will also make patients more satisfied with treatment. A randomized controlled trial in Britain tested the efficacy of educating health care providers to promote empowerment of patients (66), and found that patients being cared for by the newly trained clinicians reported having greater treatment satisfaction, better communication with health care professionals, and better emotional well-being. Educating medical students and clinicians in relevant social and behavioral sciences will improve the delivery and morale of health care.

Conclusions and Future Directions

Most Americans continue to heavily rely on physicians to treat disease or illness and improve health. The adequate education of physicians and health care providers is pivotal to the welfare of America. Medical education is a life-long process, and as research progresses, physicians need to be trained to adapt and integrate new findings into practice. Research has indicated that social and behavioral factors play a significant role in disease, and this requires that physicians receive training to understand this interplay. In addition to medical education reforms, current medical professionals need to take continuing education courses in social and behavioral sciences to ensure that physicians are competent and up-to-date with research findings. The integration of social and behavioral science principles in medical education hold immense promise and importance in addressing many of the issues in medicine today.

There are significant challenges in medical curriculum reform, and in raising interest in social and behavioral sciences within professional circles. But a movement to improve medical education by including social and behavioral sciences is necessary. In addition to curricula reform, there is an urgent need for more educators in social and behavioral sciences. The National Institutes of Health and private foundations need to put a greater emphasis on funding career development and research in social and behavioral sciences, with the aim of raising future professors and leaders in these arenas. The government also has a responsibility to protect patients from inadequately trained physicians, and ensure that physicians are competent in medicine. A requirement to have social and behavioral science courses in medical school curriculums as a condition of medical school accreditation would aid the process of implementing changes. In addition, greater inclusion of social and behavioral subject matter by the National Board of Medical Examiners in preparing board exams would encourage greater education of social and behavioral science principles. Although change is a formidable challenge, our health care system is in desperate need of improvements to promote health and well-being of the American people.


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