Handbook of Health Communication

By Teresa L. Thompson; Alicia M. Dorsey et al. | Go to book overview

6
The Nature of the Therapeutic
Relationship and the
Assessment of Its Discourse
in Routine Medical Visits
Debra Roter
Johns Hopkins University School of Public Health
Kelly S. McNeilis
Southwest Missouri State University

HISTORICAL PERSPECTIVE

In one manner or another, the construct of the physician-patient relationship and its expression through the medical dialogue has been described or alluded to in the history of medicine since the time of the Greeks (e.g., Plato's The Gorgias) and in the modern medical and social sciences literature for the past 50 years (Engel, 1977; Freidson, 1970; Parsons, 1951; Szasz & Hollender, 1956). Nevertheless, historians of modern medicine have tracked an undeniable decline in the centrality of communication to the care process. In his study of the history of physicians and patients, Shorter (1985) attributes the denigration of communication to the ascendancy of the molecular and chemistry-oriented sciences as the predominant 20th-century medical paradigm. This change was fundamental in directing medical inquiry away from the person of the patient to the biochemistry and pathophysiology of the patient. It was not coincidental that the practice of interviewing patients from a written outline designed around a series of yes/no hypothesis-testing questions replaced unstructured medical histories at this point in the history of medicine. White (1988) lamented that, because of this shift toward a biomedical focus, physicians fail to recognize that “apples are red and sweet as well as being composed of cells and molecules” (p. 6). Lacking a pathway to collaboration and partnership, many see the need for fundamental reform in medicine's vision. Just as the molecular and chemistry-oriented sciences were adopted as last century's medical paradigm, incorporation of the patient's perspective into medicine's definition of patient need has been suggested as the medical paradigm of the 21st century (Engel, 1988; White, 1988; McWhinney, 1989).

The medical dialogue is the fundamental instrument through which the battle over paradigms is being waged; the patient's problem will be anchored in either a biomedical and disease context or a broader and more integrated illness context that incorporates the

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