Doctor-patient relationships in chronic illness: insights from forensic psychiatry

Introduction

Chronic diseases are the world's leading cause of death and are projected to increase substantially to become the main cause of disability by 2020.1 In response, a common core of strategies for managing chronic illnesses has been identified that emphasises the importance of collaborative care.2 However, less attention has been given to the effect of managing chronic illness on the doctor and how this manifests in the therapeutic relationship. We draw on our work with patients in a high secure psychiatric hospital to highlight this gap and suggest how it may be addressed in medical education.

Do doctors want to manage chronic illnesses?

Most medical students want to become doctors to heal patients.3 In reality, most will spend much of their time caring for patients for whom no cure is possible. Medicine's success in the pursuit of cure has fundamentally changed the expectations of doctors; medical success has often become equated with cure and medical failure with the absence of effective treatments and resort to palliative care.4 The treatment of chronic disease conflicts so fundamentally with these expectations that it tends to be neglected.

Medical education may contribute to the development of negative attitudes towards people with chronic illness. Studies report medical students' ambivalence towards the management of chronic illnesses, even if these attitudes were absent before medical school, and a trend towards cynical and self protective strategies as training progresses.5 Furthermore, medical students are deterred from choosing specialties that involve managing chronically ill patients.4 This is perhaps unsurprising given that the dominant model of medical education remains disease oriented, hospital based, and intent on cure. This mismatch between the way that medical education is delivered and the reality of medical …