The doctor-patient relationship during medical internship: The evolution of dissatisfaction

We prospectively examined perceptions of the doctor-patient relationship among interns in two different internal medicine training programs five times during the internship year. All 59 interns in the University of California, Irvine-Long Beach and the Oregon Health Sciences University Medical Programs participated in the study during the 1982-1983 internship year. We serially administered a questionnaire that contained four major items: (1) a choice of one of six empirically developed role paradigms of the doctor-patient relationship; (2) a checklist of positive and negative aspects of internship; (3) a measure of level of satisfaction with the decision to become a physician; and (4) a rating list of mood descriptors. The six role paradigms portrayed a variety of positive and negative aspects of the doctor-patient relationship. At the beginning of the year, the interns were quite positive about the doctor-patient relationship and preferentially endorsed collegial models. As the year progressed, they endorsed significantly fewer positive and more negative models (P <0.001). Most respondents endorsed two models, one positive: "expert resource (doctor)-active cooperative participant (patient)" and one negative: "clerk, paperwork processor (doctor)-subscriber, seeker of eligibility (patient)." By the end of the year approximately half of the interns endorsed a positive and half a negative model. Interns selecting a negative model of the doctor-patient relationship identified more negative and fewer positive aspects of internship than those selecting a positive model. Specifically, they significantly more often (P < 0.001) identified too much paper work and coping with difficult patients as negative aspects of internship. They also felt more anxious and depressed (P < 0.001) and less competent and satisfied with their decision to become a physician (P < 0.001). These findings may represent partial displacement of initial performance anxiety to a more generic discontent that includes patients and the 'system' and is reinforced by the realities of internship in large, bureaucratic institutions.