A discussion of the state of health care in the United States usually focuses on the big issues: the high cost of medicine, insurance, malpractice. But there are also problems on a smaller scale: in the relationship between doctor and patient. Patients' complaints include their doctors don't give them enough time, don't answer in an emergency, and keep them waiting forever during office visits. Physicians, on the other hand, say patients oftentimes don't comply with their treatment regimens and hide their complete health histories.

Doctors in American TV shows of the 1960s and '70's, like Ben Casey, Dr. Kildaire and Marcus Welby, MD, never failed their patients. They were always knowledgeable, beneficent and caring for respectful, trusting and grateful patients. But during the last 20 years, physicians have encountered new pressures and demands that never existed in Dr. Welby's day. Cardiologist James Pope says government regulations have increased as medical knowledge has evolved.

"Now, we can keep people going for years, we can turn conditions that used to be fatal early in their course into chronic conditions," he said. "That leads to more interactions with the health system. There is more medical knowledge to be shared with patients, more things they can do to affect their health care, and it really placed a strain on the doctor-patient relation."

Dr. Pope is the chief medical officer for American Healthways, a disease-management company. As part of an effort to redefine the relationship between patients and physicians, American Healthways helped organize a doctor-patient summit.

"There were a number of tips that we discussed at the conference that could be used immediately to improve relationships between patients and doctors," said James Pope. "There were some that needed more development, more changes in the way the health system works. One of the surprises at the meeting was how interested both the patients and physicians were in accomplishing the same thing. The doctors, though they're often portrayed as being somewhat aloof, are in fact very interested that the relationship be good."

One of the participants, Dr. Fredrick Brancati of Johns Hopkins University, noted that a big obstacle to a good relationship is the current health care system. "As the primary care itself has become a smaller and smaller component of the whole practice of medicine as the specialty care and technical oriented care expanded, I think the focus on that relationship has diminished," he said. "As process of care industrialized and time managed more in the medical practice, what gets squeezed, I'm afraid is that relationship, even as efficiency has improved."

Jeanne Sievers, a member of the patient steering committee for the summit, says time is a concern for both patients and physicians.

"One thing is the time issue with both the physician running late as well as the patient running late and setting off the doctor's schedule," said Jeanne Sievers.

Ms. Sievers says, when visiting their physicians, patients have the responsibility to be prepared.

"They need to be aware of why they're going to doctor," she said. "What are the main symptoms, what are their concerns? They may have a concern that's not showing in the symptoms, they need to write it down. What is that they are looking for a doctor to accomplish at that particular visit. When they come with preparation like that, it assists the doctor in becoming more effective from his/her side. That improves the relationship."

In return, cardiologist James Pope says doctors should be prepared for their patient's visit.

"Doctors should work on being very open about office policies," said James Pope. "Patients often really have to figure out how to interact with the office on their own, almost by trial and error more than a careful understanding of what they can expect. The doctor should also promote a dialogue. One things we learned from the meeting was how often the social religious or culture issues might affect the way a patient is going to take action on the recommendations the doctor has given."

'Work on inter-personal skills early and often' is a recommendation that made sense to Johns Hopkins professor Dr. Brancati. He says it's important to keep medical students exposed to doctors who take the time to really get to know their patients.

"We've done studies, as part of the summit, with residents in training in medical schools asking them what they consider as role models," said Professor Brancati. "They generally rate as highly people, faculties not based on their technical skills or their research productivity, but based on their communication skills and interpersonal grace and focus on social and psychological aspects of disease, even when they are highly sub-specialized instructors."

Redefining the relationship between patients and physicians might lead to some changes in the way doctors practice medicine. The next patient-physician summit, in June, will continue to explore different aspects of this relationship, offer solutions and help shape a more effective health care system.