The Effect of Social Changes on the Doctor-Patient Relationship

Shapiro, Edward R. M.D.

In this paper, I will explore from a psychoanalytic and social systems perspective, the effect of impinging social changes on the doctor-patient relationship in America. I will illustrate how the massive expansion of managed care, regulatory agencies, pressures on confidentiality and the technological and biological revolution in health care has exacerbated the pressures on the therapeutic dyad. Though the therapeutic dyad has always been imbedded in a larger institutional world (hospitals, health care systems/ professional standards), the shifting social response to dependency in this country has resulted in the formation of powerful third-party care-systems, organizations that control the nature of compensation and assess the conditions necessary for payment from outside the doctor-patient dyad. This new American system has transformed our understanding of treatment, the nature of doctor and patient roles and the structure of their respective authorities. This has evoked significant disarray. Seen most clearly in the setting of dynamic psychotherapy, this transformation is also manifest in changes in the doctor-patient relationship in medicine generally. Paying attention to this larger social context might allow both doctor and patient to take up more active roles in the changing nature of health care without losing the increasingly endangered primary focus on the treatment task.

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