The Value of the Therapeutic Relationship Between Patient and Health Care Professional

What is the nature of the relationship that a patient has with a health care provider and does it play a role the health and wellness of individual patients?

The answer depends on the nature of the patients’ visit and the focus or specialty of the health care professional. For psychotherapists, the therapeutic relationship is the core clinical tool and very little progress will be made if it doesn’t exist. On the other end of the spectrum are technical specialist such as anesthesiologists, pathologist, and radiologists who work behind the scenes and have very little interaction with patients. However, for these specialists, a patient assumes the level of the practitioner’s competence has been reviewed and approved through licensing and credentialing processes by hospitals or state boards. In other words, these specialists have been sanctioned by authoritative sources carryout their fiduciary responsibilities.

In between the two extremes, are primary care providers and a wide variety of medical and surgical specialists. The major difference along this continuum is the on-going relationship with PCPs and some medical specialists (e.g., cardiologists) verses the episodic relationship with most surgical specialists and some medical specialists (e.g., dermatologists). I believe that that greater frequency of contact that a patient has with a provider, as well as the comfort of knowing who to call when urgent needs arise, drives the value and impact of the therapeutic relationship (VITR). A high degree of VITR will likely motivate patients to comply with health and wellness regimes (e.g., diet and exercise routines) as well as treatment protocols. In general, this emphasizes the role of PCPs where the frequency of patient/provider contact is highest.

At the Marino Center, there is a strong belief in VITR. To this end, patients are provided with a generous amount of time with their providers. While time is not the only element that builds VITR, it’s a good start.

Pillars of Integrative Healthcare

The Marino Center defines integrative healthcare as not only the combination of conventional medicine with complementary and alternative medicine (CAM) in one clinical setting, but as care focused on health and healing with an emphasis placed on the patient-provider relationship.

The key components of the Marino integrative healthcare model are presented below. Supplementary to these core services are various group programs focused on improving and maintaining a state of well being. Such programs include stress reduction, weight loss, and yoga.

While any one of the services listed below can be helpful for the conditions noted, the true value of an integrative care approach is that the practitioners in each of these disciplines collaborate with each other to move the Marino Center patients to their optimal health status.

Acupuncture
Acupuncture is used to relieve pain and heal a variety of conditions, including arthritis, asthma, PMS, stress, digestive problems, muscular injuries, and more.

Chiropractic
Special attention is given to spinal biomechanics as well as musculoskeletal, neurologic and nutritional relationships.

Craniosacral therapy
Therapists work with the spine and skull to treat mental stress, neck and back pain, migraines, TMJ Syndrome, and for chronic pain conditions such as fibromyalgia.

Environmental medicine
A comprehensive approach to evaluating, managing and preventing the adverse consequences of environmentally triggered illnesses, including allergy testing and treatment.

Massage Therapy
Massage Therapy can be used to treat a variety of medical conditions, including sports injuries, asthma, PMS, lower back pain, arthritis, Carpal Tunnel Syndrome and stress.

Mental Health
Individual, group and couples psychotherapy to help you identify and change the way you respond to life’s stresses.

Nutrition counseling
Examines the critical role of food in health maintenance and disease prevention. Helpful for a wide variety of conditions, including obesity, diabetes, pregnancy/fertility and allergies.

Pain Management
A variety of treatments for pain, including acupuncture, massage, energy healing and chiropractic.

Physical Therapy
Physical therapists provide services to patients who have impairments, functional limitations, disabilities, or changes in physical function and health status resulting from injury, disease, or other causes.

Primary care
Primary care with a significant difference: Extended visits, strong personal relationships with an emphasis on screening and prevention, and discussion of diet, exercise, stress and lifestyle.

The Myth of Early Detection – Evidence Based Medicine?

One of the key questions raised about treatments that differ from mainstream medicine is "what is the evidence that it is safe and effective?" A very valid question indeed. Clearly it is imperative that we learn what works and what doesn’t. But, it is not quite that simple. Some approaches work for some people and not for others and it is the experience and skill of the clinician to make the right match between a patient’s condition and the best clinical approach. In other words, the clinician must practice the art of medicine.

In recent days, several studies have been released that bring back into the spotlight the questionable validity of the assumption that early detection of a disease and the screening required to make this detection is the gold standard of quality medical practice. The two screenings for early detection that are most common are PSA for prostate cancer and mammography for breast cancer. Indeed medical practices are measured and rewarded based on achieving high percentages of their patient populations getting such tests. The higher the percentage screened the more "pay for performance" dollars flow to the practice. The economic incentives trump clinical value. The authors of these studies argue that the public is not currently presented with a balanced view of the screening, with potential benefits overemphasized and potential harms rarely discussed.

The conclusions of these studies have shaken conventional medical thinking. It makes me think of the old adage "half of what is learned in medical school is wrong, the only problem is figuring out which half".

Unfortunately, the recent studies do not provide much guidance to patients and their physicians other than to provide a balanced view. I suspect that most patients are not going to say "thanks for information doc, I will do more research and analyze what I find and get back to you with my decision". They are more likely to say "so what do you recommend that I do?" The response in all likelihood, despite conflicting evidence, is that the patient should go ahead with the screening. Why, because of fear of a malpractice charge for missing a cancer diagnosis and the economic incentives mentioned above.

The bigger issue than these specific study findings is what else do we take as absolute truth in medicine that is wrong? In discussing this issue with John Bordiuk, one of the Marino Center doctors, he said the only "absolute" truths in preventing illness and maintaining wellness is eat a proper diet, get a decent amount of exercise, get adequate sleep, and control stress levels. This is more powerful in protecting health than any screening tests we know. Not very high tech but it works a majority of the time for most people.