Medical diagnosis determined by the physician is a complex, bio-psycho-social one [5, 31, 32] hence, to understand the whole, the components need to be understood too. Since patients and physicians often disagree on what is perceived as “good health service” [33, 34], the goal of our study is to assess the most important aspects of the patient–physician relationship from the perspective of the physician and compare it to the views of the patients (based on existing literature). Utilizing this comparison, we can shape a more holistic view of this dyadic bond. Notably, if each party refers to different aspects of the relationship and defines it in their own way, it is essential to bridge this gap between the parties’ perceptions in order to build a stronger relationship, leading to better treatment outcome.
Identifying the constructs patients use when making physician choice decisions, and especially their evaluations of subjective quality-related choice criteria, is of increasing importance to the health care business . This is because the role of the patient in the hospital and physician selection process has grown. The increase in customer choice and the inherent complexity of the medical facility choice process have become more apparent, especially with increased privatization and the profit orientation view . Accordingly, to better understand and align this relationship, physicians’ views must be examined.
A variety of studies have shown that physicians and patients have different views regarding what might be effective communication between them. These views influence the perceived quality of the medical service rendered (Berger et al., ). Acquiring communication skills in times of change and uncertainty can lead to a competitive advantage. Medical educators should use patient–physician perceptions of care and focus on the areas of teaching that will help practitioners to meet patients’ expectations. Table 12 summarizes the differences in views of what is considered good medical service (see Appendix C).
No doubt that the asymmetries noted in the patient-physician relationship is derived mainly from the differences in health seeking behavior, and use of the internet. According to Moorhead et al.  several key ways that social media are being used today in healthcare: to provide information on a range of issues; to provide answers to medical questions; to facilitate dialogue between patients and health professionals; to collect data on patient experiences and opinions; to use social media as a health intervention, for health promotion and health education; to reduce illness stigma; and to provide a mechanism for online consultations. Thus, these diversified ways increase availability of health information but at the same time increase variety of opinions some objectives and some subjective.
Initially, medical journals focused on the medical act itself: interventions, hospitalization and the administrative side [37, 38]. Later, these journals started studying non-medical factors such as patient–physician relationships, organizational climate, and benefits provided by health providers outside the strict health services given [39, 40]. Over time, the patient–physician bond has evolved because of such developments as improved patient involvement in the medical procedures and doctor and/or facility choice, while reducing the passive acceptance of therapeutic indications as is. Patients’ responsibility regarding their own well-being has increased as well as the degree of information they have. Their demand for more knowledge and involvement from their physician has also grown. Numerous scholars have argued that traditional, symptomatic-oriented medicine is being replaced by patient-centered medicine where the physician invests more time on the patient’s problems and not only medical but also psychological and social ones. It was found that most patients want an active collaborative and humane involvement in the management of their own illness .
One study that examined the perspective of both parties was that of Krupat et al. , which was more qualitative in nature. The study indicated that from the perspective of patients, trust was established when power and information were shared by physicians, whereas physicians were apparently less affected by these aspects shaping patients’ attitudes. We claim that such incongruence may cause mistrust between patients and physicians, and lead to misunderstandings. The study further claimed that from the physicians’ perspective, the patient–physician relationship is rational and practical in nature. Again, this rational view by physicians is incongruent with the patients’ view, which is subjective in nature, emphasizes information sharing and empathy and takes into account their emotional state . Thus, while Bendapudi et al. , who focused on the patient’s perspective, claimed in their qualitative research that physicians’ openness to sharing with their patients in an empathic manner all aspects of information collected leads patients to trust their physicians more, physicians may define this relationship with their patients one-sidedly. They provide their patients with information based on rational indexes and less on emotional indexes and data, an area with which they may feel less conferrable with—a point that needs to be further explored.
In many service contexts and especially in the medical industry, customers do not know the appropriate level of service required for their specific needs . They rely on the advice of an “expert” who typically also provides the subsequent service. For example, the Hippocratic Oath of a physician controls for the problem of under-treatment in the medical services. The separation of physicians and pharmaceutical and other medical service providers is intended to circumvent overtreatment by unravelling the motivations to prescribe medications and market medical facilities from the revenue made by selling them. There is a continuing discussion in the health care literature about the presence of physician-induced demand . Physicians may offset the drop in the number of customers by a rise in the scale and scope of care delivered in each encounter. For instance, research has shown that the incidences of cesarean deliveries compared to standard child births are linked to the remuneration differences of health insurance policies . Medicine has become like any profit-oriented business, serving markets rather than patients, and focused on throughput rather than patient-centered care. This is highlighted in the CNN headline, “Patients give horror stories as cancer physician gets in 45 years” . Conflicts of interest are accountable for an abundant amount of ethical wrongdoing . Defensive medicine is another important issue in medical services. This term refers to physicians ordering tests and procedures, making referrals or taking other steps to help protect themselves from liability rather than to benefit their patients’ care . This certainly results in the “overuse of medical services” solely to ensure that the physician is protected from a malpractice lawsuit. As a result, it is very difficult for a patient to assess if he or she is getting the right amount of medical care or is over- or under-treated. It is important to note that it is also very difficult to assess the gap, if one exists, between the level of treatment needed to the one given ad hoc or post hoc, thus increasing the perceived risks.
Value from a service rendered is frequently fashioned within the setting of the supplier–buyer relationship . Relational significance is considered as the professed net worth of the tangible benefits that emerge over the period of the relationship . Some goods and services, due to their complexity, can mainly be delivered within the framework of a relationship where the buyer is compelled to trust the supplier, which is characteristic of the medical service industry . Medical treatments offer the most complicated and maybe the most important environment within which trust should foster. For many diseases, no satisfactory treatment exists, with others success is only random. Thus, a failing treatment is no perfect signal of under- or over-treatment. These types of goods and services are called “credence goods”—goods/services whose quality when rendered cannot be measured even after their receipt .
Credence goods are goods and services traded within interactions categorized by high levels of information asymmetry, where it is the supplier who regulates the buyer’s needs . Many professional services have the attributes of credence goods, as they are often customized , requiring intensive interaction from both parties to create value . Quality can neither be hypothesized nor assessed by customary approaches because of credence goods’ three characteristics: heterogeneity, intangibility and inseparability . The key feature of credence goods is that consumers do not know the quality of a good or service they need or are receiving before purchasing, during its usage, or after receiving it. Perceived quality of medical treatment must, accordingly, be based on non-objective cues such as perceived trust based on the dyadic relationship created, word-of-mouth, the way a physician approaches the patient, diplomas, and how the physician’s facilities look. Medical services are often considered high risk purchases, given that the level of uncertainty and perceived risks are the highest . Mitra., et al.  recognized that customers of credence goods endure this comparatively higher level of risk by constructing relationships and spending more time searching for information about the good providers than customers of search or experience goods. The mutual relationship model presented below elucidates this symbiosis.
The potential impact on credence goods can be seen in the results of a field experiment in the market for dental care of Gottschalk et al.  where an overtreatment recommendation rate of 28% and a striking heterogeneity in treatment recommendations was observed. It was found that mainly dentists with shorter waiting times are more likely to propose unnecessary treatment than others. Since patients are often left to use price as the only signal of quality, it is crucial to encourage patients to rely on recommendations from other users.
The research model
The relationship exploration model is commended as a research approach to circumvent service imperceptibility  and is suitable for exploring credence services . Recent research has illustrated that social relationships are not a single-dimensional concept . Instead of treating service provision as a discrete event (i.e., a one-off transaction), social exchange theory suggests treating this service as an ongoing relationship. The development of relationships is an intensive process that is costly, time-consuming, and does not necessarily generate an immediate result. To explore the individual relational constructs that together build a better picture of what is seen as a good quality relationship, we utilize the multi-dimensional GRX scale . The scale consists of three main constructs: (1) benevolence (i.e., mutual feelings); (2) reciprocity; and (3) trust (i.e., trust that one will do what has been promised and that one has the ability to do what was promised). Each construct is broken down into sub constructs, as presented by Yen and Barnes , which facilitate better understanding of the issues, as presented in Fig. 1. The GRX scale has been used extensively to measure the quality of social relationships in many areas, for example, organizational capabilities , leadership [61, 62], service quality in hospitality management [63,64,65], business ethics , and customer relationships . It has been further utilized in countries such as China, Russia, India, and Arab countries. A strong social relationship was found to be based upon three constructs . The first construct is the confidence that the relationship partner will act benevolently to the advantage of the relationship ; the second is that the partner will behave honestly and can be trusted to be competent in his or her role ; and the third is that the partner will reciprocate the trust given, creating a long term relationship .
Research has shown that social relationship quality is viewed as a higher order construct comprising multiple constructs [9, 72]. When a customer feels that she is involved in a high quality relationship, she will be satisfied with the service performance and is able to rely on the service provider . According to Parsons (2002), a strong relationship refers to the degree to which the performances meet customers’ expectations. Recall that in the medical profession, it is almost impossible to measure objectively the quality of service given, as it is a credence good . This means that even after the service is rendered and the patient did not die or suffer adverse side-effects, it is impossible to determine that if the service had been given by another physician, the outcome could have been better. Furthermore, in many cases it takes years for side-effects to become apparent. As a result, the only way to examine satisfaction in the medical field is the patient’s perceived satisfaction, in many cases based on a personal view of the outcome. The following is the discussion of the constructs comprising our model.
Benevolence (affective tie)
Benevolence represents feelings and affection, a type of an emotional attachment that signals the quality of the relationship. It is claimed that in the medical industry, knowing the patient is at least as important as knowing the disease . It is claimed that physicians with a warm and friendly style are more effective than physicians with a more formal style . Empathy could be viewed as an aspect of medicine’s sacred commitment to stand with the sick, and the fragility of existence. It is triggered by a need for companionship and mutual understanding, especially during this exposed and unbalanced relationship. Benevolence has been found to intensify satisfaction amongst exchange partners . Hence, a patient–physician relationship that demonstrates benevolence is thought to lead to better perceived care and greater patient–physician satisfaction, leading to a long-term relationship .
Trust implies credibility and, by increasing trust, one can improve relationships and increase mutual co-operation. As a rule, the patient’s trust in a physician is connected to one’s illness-generated vulnerability situation. It has been generally acknowledged that in situations in which there is a high level of perceived risk, creating trust in the service provider’s abilities necessitates a greater dependence on personal sources of information (such as friends and relatives) rather than via impersonal sources . Trust in the patient–physician relationship is akin to the trust displayed in the family cell. This relationship has a robust affective and emotional dimension . Trust is a necessary condition for medical practice; it is the “fundamental moral law for medicine” . In the past, the trust of families and patients in a physician was imbedded. Today, trust is seen as something that is built gradually through a number of exchanges, and families and their patients are seen as active contributors in the service given based upon the capacity to manage, observe, and evaluate various circumstances concerning their health situation .
We define trust as prevailing when one actor has assurance in the exchange regarding the other actor’s integrity and reliability. This is when, for example, the physician can be relied upon to deliver on his promises . Mutual trust in the medical profession is seen as a key relational building block. According to Hall et al. , trust is seen as significant in its own right because it is the construct that gives medical interactions intrinsic value. Trust can be seen as the willingness of one party to be vulnerable to a particular action that is important to the trustor, irrespective of the ability to monitor or control that other party’s actions . Over the years, numerous researchers highlighted the need for trust in the health industry and stressed the importance that the patient has faith in that the physician will look out for the patient’s interests .
Trust is critical to patients’ willingness to seek care, reveal sensitive information, submit to treatment, and follow physicians’ instructions/recommendations . Previously, the belief was that a comprehensive understanding and trust can only be built up over time through a close relationship that went beyond an understanding of the medical needs of each patient. Today, trust is viewed as a fundamental building block in the medical process. Trust is developed through repeated interactions in which the patient and one’s family observe the physician and decide if he is consistent, competent, honest, fair, responsible, and benevolent. Through engaging in actions that demonstrate honesty and extra effort, the patient develops trust in his physician . Being able to measure trust is vital for physicians because it enables them to better monitor and evaluate the trust that is integral in building a strong health system with better health and economic outcomes . Trust seems to work like a prognosticator of the endurance of a relationship between a certain patient and a certain physician. It can be seen as a motivating cause for increased adherence to wide-ranging medical instructions and recommendations related to the treatment, self-care actions and the inclination to pay attention to health in a sustained and continual method.
Researchers are increasingly focusing on defining physician-to-patient communication to show that it plays a significant role in creating customer satisfaction and improving perceived quality of medical services given . Dealing in uncertainty, risk, and the impossibility of generating a definition for the situation that would result in a solution for health creates the basis for the patient’s need to trust the medical system. It has been established that reciprocity is an important key construct in building a fruitful patient–physician relationship . Reciprocity is when one gets compensated for one’s honesty and professionalism by, for example, repeat business and referrals . This is a useful mechanism to achieve better co-operation between both parties. Even if only one member of the dyad breaks this reciprocal relationship, both parties’ interests may be damaged . Reciprocity, in our context, means matching the differing viewpoints of the patient–physician communications. Given that credence services are seen to constitute high risk purchases , this would logically imply that the reciprocity construct would take on greater significance in the evaluation of medical services. Most health service providers identify the significance of building more sustainable and long-lasting relationships with their patients . Very often, increased customer loyalty and repeat purchases are argued to be the single most important driver of a firm’s long-term financial performance and the medical industry is no different. We believe that if the physician would go that “extra mile” for the patient, the patient would reciprocate and help build a long-lasting relationship by coming back to the same physician for further treatment, hence, increasing performance and mutual satisfaction.