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.[6–8] A comprehensive review by Vermiere et al.,[9] 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.,[9] 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.[10] 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.

Adler[11] 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 our study, although physician–patient concordance and patient enablement were both around 85%, trust in the physician, which was just above 60%, was the weakest link. Males had better concordance, trust, and enablement compared to females. Patients from a higher socioeconomic status showed better concordance and trust. Women patients tended to have significantly lower trust (50%) in their physicians than male patients (75%). This may have been due to their being more reticent with the doctor during the consultation, as was observed during participant observation. Gender biases in doctor–patient relationship have also been noted by other investigators.[14–16] Street et al.[17] have also found that physicians tended to use more partnership building with male patients.

The lack of trust in the physician, by almost 40% of the patients, has implications for the management of many illnesses, which require long-term treatment. An important example in developing countries is tuberculosis, where one of the major reasons for treatment failure and emergence of drug-resistant bacterial strains is poor compliance on the part of the patient and treatment dropouts. Efforts should be made to ensure better trust in doctor–patient encounters. Although we should be cautious in assuming that concordance and trust means better compliance,[6–8] there is empirical evidence that patients reporting a higher level of trust in physicians are more likely to report continuity of care and compliance with medications.[5] Zolneirek and DiMatteo[18] in a meta-analysis found that communication in medical care was highly correlated with better patient adherence, and training physicians who communicated better, enhanced their patients’ adherence to treatment. The UK's National Institute for Health and Clinical Excellence (NICE) guidelines states that adherence to treatment presumes an agreement between the prescriber and the patient about the prescriber's recommendations.[19]

An important finding in the present study, which has an implication for practical application, is that better doctor–patient concordance has a strong and highly significant association with trust in the physician, which in turn has a strong and highly significant relationship with patient enablement or empowerment. The key to patient empowerment is through better doctor–patient concordance or agreement.

Portmann, cited by Chin,[20] has compared the doctor–patient relationship to a marriage, where initial high hopes often obscure the possibility of disappointment, where subsequent unmet hopes can lead to a terrible loss of faith. This breakdown in trust has also prompted the suggestion of viewing the relationship purely as a contract sustained by pre-set terms and conditions in order to meet the minimum standards of care. Chin[20] argues that this approach is unfortunate and does not benefit patients, as much of the concerns regarding the weakening of the doctor–patient relationship stems from the threat posed by the rapid change in the healthcare system.

Some of the challenges in improving this concordance, and in turn the trust between doctor and patient, have been brought out in the qualitative inputs from focus group discussions among selected physicians. In brief, they are decreasing the importance of the general and family physician, language, cultural barriers (albeit no association has been revealed quantitatively in the present study), and alternative remedies, and increasing the commercialization of medical practice.

The current medical care environment is complex, including the rise of consumerism, increasing litigations, high-pressure marketing, easy access to medical information via internet, and poor access to reliable healthcare causing overcrowding in many medical centers. The interaction between anxious patients and busy doctors can lead to a lack of concordance and other communication gaps. Exposure to media reports of medical negligence can further erode the public trust in medicine as an institution, a trust that is declining during the last decade.[21]