Understanding the dynamics of the patient-physician relationship: balancing the fiduciary and stewardship roles of physicians

There has been growing concern about the effects on the patient–physician relationship of the increasing demands on physicians to balance their fiduciary and stewardship responsibilities, what has been called double agency. Various authors have proposed ways to restore patient centeredness to the patient–physician interaction. We have previously discussed the need to establish a patient–physician alliance to achieve this aim and to facilitate achieving this balance in mutual understanding. In this essay, we examine six concepts derived by Michael Balint from research seminars with primary care physicians. These six concepts are (a) the basic fault; (b) the physician's apostolic function; (c) the mutual investment company; (d) the drug doctor; (e) the deeper diagnosis; and (f) the conspiracy of anonymity. We believe these six concepts describe basic forces that shape the patient–physician relationship and allow for the development of an alliance between patients and physicians that can help preserve the essentials of the relationship.