Doctors and patients, even if they come from the same social and cultural background, view ill health in very different ways.[1
] The challenge is how to ensure some communication
between them in day-to-day patient care. Rapid advances in medical technology pose further challenges. There has been a shift in recent years in how doctors collect information about underlying disease processes.[2
] The traditional method was by listening to the patients’ symptoms and then searching for objective physical signs. Increasingly, however, modern medicine has come to rely on a battery of tests to come to a diagnosis. The underlying pathological processes are now firmly identified by blood tests, X rays, scans, and other investigations carried out in specialized laboratories or clinics.
As Kleinman et al
. put it, the modern doctor's view of clinical reality ‘assumes that biological concerns are more basic, ‘real’, clinically significant, and more interesting than psychological and sociocultural issues’.[3
Cassel uses the word ‘illness’ to stand for ‘what the patient feels when he goes to the doctor’, and ‘disease’ for ‘what he has on the way home from the doctor's office’. He concludes: ‘Disease, then, is something an organ has, and illness is something man has’.[4
Specialization and super-specialization is producing a breed of doctors whose professional aim is to know more and more about less and less, and paradoxically, they enjoy a higher status than the generalists. They also act as role models for medical students to emulate.
These developments are putting a further strain on the fragile doctor–patient relationship, as evidenced by the increasing trend in medical litigations.
With rapid social changes on one hand and advances in medical technology on the other hand, studies on the changing doctor–patient relationship, particularly in developing countries, are indicated. Most developing countries comprise of many social and cultural entities, with diverse languages, customs, religion, and so on, which provide ample opportunity to study how these sociocultural factors affect the doctor–patient relationship.
The findings of such studies will provide some inputs for improving the communication between the patient and doctor. This in turn will have a positive impact on patient care and management and hopefully reverse the rising trend of medical litigations.
However, conceptualization of various dimensions of the doctor–patient relationship for an objective study poses certain difficulties. As the doctor–patient interaction does not take place in a vacuum, but in different social and cultural environment, it may be influenced by sociocultural factors. Besides, there is no consensus about the importance of various dimensions of the doctor–patient relationship. For example, the role of doctor–patient ‘concordance
,’ which has been used to denote an ‘agreement
’ between physician and patient[5
] is hotly debated.[6
] A comprehensive review by Vermiere et al
] which spans three decades of research on patient adherence to treatment, while conceding that the concordance model points to the importance of patient's agreement and harmony in the doctor–patient relationship, revealed lack of consensus on the measurement of compliance and definition of adherence. These limitations preclude assuming that concordance leads to compliance or adherence. The backbone of the concordance model, according to Vermiere et al
] has the patient as a decision-maker and a cornerstone in professional empathy — however, as concordance is not the same as compliance or adherence, more high-quality studies are needed to assess the determinants of non-compliance. Bissell et al
] state that the concept known as concordance
is attracting increasing interest in health services research. In a qualitative study among diabetics they have found that patients sought greater understanding and appreciation by health professionals of the subjective aspects of living with diabetics.
] goes a step further when he discusses the sociophysiology of caring in the doctor–patient relationship. He infers that besides the justification of a caring doctor patient–relationship on humane grounds, it can also be justified as a direct physiological investment. He speculates that caring as a sociophysiological engagement may provide a unitary concept for understanding the health consequences of social support and the doctor–patient relationship for both doctor and patient.
In the present study our research question is, what are the sociocultural determinants of three dimensions (concordance, trust, and patient enablement) of the doctor–patient relationship and also what are the inter-relations between these three? We defined doctor–patient concordance as an agreement measured by a set of questions suggested by Kerse et al
] Similarly, trust was measured in the manner suggested by Anderson and Dedrick.[12
] We measured patient enablement (empowerment) by the Enablement Index suggested by Howie et al