Way back in 1992, Ezekiel and Linda Manuel described the physician’s four distinct roles in patient relations: guardian, technical expert, counselor, and friend. The Manuel model is still widely cited today, but do these roles still apply, more than two decades later? We took a look at each in light of recent trends.

Physicians are still seen as guardians against disease, complications, and suffering. It’s a foundational part of medical practice. In the past few decades, though, we have seen an expanding trend toward patients taking more active responsibility for their health through care models like the IOM’s Patient-Centered Care, shared decision making, and disease self-management. The physician is still a guardian, but the patient relationship now is more partnership than paternalism.

Health-conscious patients combined with the internet can sometimes threaten the physician’s traditional role as technical expert. “I appreciate that they’re involved in their own health, and I don’t want to discourage that at all,” says Theresa Rohr-Kirchgraber, MD, Past President of the American Medical Women’s Association (AMWA) and a founding member of The Doctor-Patient Rights Project. “At the same time, I will caution them.”

While this trend can be seen as a negative, the avalanche of health information in the internet age can also be an opportunity to strengthen relationships with patients: they need your technical expertise more than ever to sift through it all. “When patients hear it from me, they know I’m coming at it from a point of compassion and empathy, and also knowledge,” says Rohr-Kirchgraber. “Explain things as much as possible. Use visuals, show them pictures. Then they have more buy-in.”

There is still plenty of opportunity for physicians to counsel patients, but there is a new offshoot of this role that can have a big impact on patient relations: discussing patient costs. The 2018 Medscape Physician Compensation Report found that only 40% of physicians regularly discuss treatment costs with patients. But with the trend toward high-deductible health plans, many patients are seeing higher out-of-pocket costs—and often blaming healthcare providers for it.

Now, the counseling role includes “talking to patients when they get a bill and they’re upset about it,” says Rohr-Kirchgraber. It also includes discussing costs and coverage with the patient before tests and procedures are ordered, and educating the patient on their responsibility for communicating with their insurance carrier. “I would encourage patients to talk to their physicians about this,” she says. “Their physician is on their side, we’re in this together.”

This is a tricky one, and it is even trickier now that “friend” is also a verb. Social media and other means of instant electronic communication can be powerful tools for relationship building, but they can also blur the boundaries.

Of course, there is a generational factor at work here: a recent American Osteopathic Association survey found that 65 percent of millennials think it is appropriate to use social media to contact their physician about a medical issue, while other studies have found that patients between 65 and 80 years of age far prefer speaking with someone on the phone or in person. But there is no denying that communication and accessibility are major components of the “friend” role, and—for many patients—technology is an inexorable aspect of both.

Something as simple as email communication can have real value. Not only does it provide a convenient, flexible option for doctor–patient communication, it also automatically provides a written record of the exchange. Nurses can triage messages first, and forward only more complex messages to the physician. Rohr-Kirchgraber uses this system in her practice and finds it invaluable. “So many [emails], I can answer quickly, and the patient feels heard,” she says. And with the triage approach, “the number [of emails] I get is really not that much.”

But keep in mind that no technology will ever replace a physician’s ability to connect directly with a patient in conversation. “It’s more than ‘What pill are you taking?,’ it’s ‘What’s going on in your environment?’” says Rohr-Kirchgraber. “The exam room is one place where you can talk to people in a confidential way. [Patients] need that one-on-one time so they know I’m invested in them.” The ability to talk and listen to patients brings all four roles together—and that is something that will never change.

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