This chapter discusses a variety of practices the healthcare education community can adopt from the psychotherapy literature regarding therapeutic alliance training when supervising trainees, and provides a series of recommendations, grounded in the extant literature, to bring these practices to life. In addition to describing how healthcare educators can translate Bordin's therapeutic alliance model to the medical and allied health communities, this chapter discusses aspects of therapeutic alliance facilitation and maintenance supervisors can address explicitly in supervision, including attunement to the developmental stage of trainees, using the supervisory alliance with trainees, addressing issues of diversity and multiculturalism, and increasing trainee self-awareness in the service of alliance maintenance. Specific strategies including role-play, alliance measurement, and use of video/audio recording are discussed. Supervisors can apply these nomothetic concepts to their scopes of practice and address idiographic concerns with trainees that emerge in their patient populations.
TopIntroduction
The patient-provider relationship is a cornerstone of medical practice. This relationship impacts all clinical interactions and is recognized by the healthcare and lay communities as an integral part of treatment. Healthcare providers across disciplines have considerable latitude to adjust their approaches to the patient-provider relationship to maximize the benefit to clinical care (Beach, Inui, & Relationship-Centered Care Research Network, 2006; Dorr Goold & Lipkin, 1999; Szasz, Knoff, & Hollender, 1958).
The strength of the patient-provider relationship is linked to increased patient satisfaction with clinical care, increased treatment adherence, and better treatment outcome (Chipidza, Wallwork, & Stern, 2015; Fuertes et al., 2007; Fuertes, Toporovsky, Reyes, & Osborne, 2017). Birkhäuer and colleagues (2017) conducted a meta-analysis examining a patient’s trust with their healthcare provider and its relation to clinical outcome, and found a small to moderate correlation between patient trust and self-rated subjective health outcomes (e.g., adherence to medication, health-related quality of life). They also found a large correlation between trust and patient satisfaction. Conversely, poor clinical outcomes as noted by objective measures or standardized subjective metrics have been found when patients feel unheard, disrespected, or otherwise out of partnership with their physicians (Chipidza, Wallwork, & Stern, 2015; Gordon & Beresin, 2016; Ong, de Haes, Hoos, & Lammes, 1995).
Attention to the relationship is advocated by multiple healthcare professional organizations. The American Medical Association’s (AMA) Code of Medical Ethics highlights the importance of patient-provider relationships, stating “the practice of medicine, and its embodiment in the clinical encounter between a patient and a physician, is fundamentally a moral activity that arises from the imperative to care for patients and to alleviate suffering” (AMA, 2016). The American College of Physicians Ethics Manual also stresses the importance of the patient-provider relationship:
At the beginning of and throughout the patient–physician relationship, the physician must work toward an understanding of the patient's health problems, concerns, values, goals, and expectations. After patient and physician agree on the problem and the goals of care, the physician presents one or more courses of action, with a specific recommendation for the patient. (Sulmasy & Bledsoe, 2019, p. S3)
Given the stated importance of this relationship, it is critical for healthcare providers across disciplines to learn to cultivate strong patient-provider relationships. Thus, this chapter describes several strategies that can be used to teach trainees ways to strengthen the patient-provider relationship.