This journal, in common with all orthopaedic journals, publishes a large number of articles commenting on and describing technical advances in diagnosis and in techniques [1,2,3,4]. There are very few articles on the relationship between clinicians and their patients [5,6,7,8,9,10,11]. That therefore misses the crux of successful interaction between us, the surgeon and our target audience, the patient.

I have noticed an increasing tendency for the patient to be ignored, particularly in theatre. The anaesthetist is sitting down reading a file, looking at the phone or the anaesthetic apparatus. The nursing staff are turned away filling in administrative and quality-tracking forms. The radiographer is checking social media unless actually providing views, and the assistant is listening to the radio. It may happen that the sole individual looking at the patient is the surgeon!

The medical training provided in the 1970s set great store by the interaction between the patient and the clinician. This is variously described as bedside manner. The Cambridge dictionary describes that as ‘the way in which a doctor treats people who are ill, especially showing kind, friendly, and understanding behaviour’. This description would appear obvious to most clinicians and even we orthopaedic surgeons. It essentially describes how we would all like to be treated if and when we or our family become patients. When applying for a place in medical school, we were interviewed unlike applying for degree courses in other subjects. The purpose of that approach was to determine those people that were unlikely to be able to communicate effectively with their patients. There is no point in having a brilliant mind but no mechanism of expressing it. The clinician needs to develop a rapport with their patient to achieve that, and therefore, it is worthwhile spending a little time in general conversation at first. Putting a patient ‘at their ease’ allows a genuine two-way sharing of information to the benefit of both.

The problem now is that there is an increased reliance on investigations with a result that clinical acumen is reduced and the results or reports of scans take precedence. We were always advised to treat the patient not the x-ray or, nowadays, the scan. This situation is likely to become more acute with the rise of artificial intelligence which can certainly improve diagnosis but not the interaction with a patient. That remains human, at least for the moment. Often, the most important observation is whether the patient is ill or not. That informs whether urgent action is needed or not and has the potential to be life and limb saving. It is the ability to ‘read’ the situation or use intuition which sets us apart from the machine.

We must remember that we are human with all the aspirations, fears and attributes that encompass. To be a skilled clinician means being able to provide the support, information and treatment options our patients would expect [5]. With the challenges of more informed and demanding patients, we must improve and practice our interpersonal skills. Although patients these days are far better informed than they used to be and often come into consultations clutching articles obtained from Mr. Google or from the golf club, we as clinicians need to put this into relevant context [6]. Information for patients is certainly key as an informed patient is a more understanding and cooperative patient as they can understand the reasoning behind clinical decisions. A properly informed patient is a patient that will be more compliant with the treatment we propose. Information presented in a way our patients can understand is key. This information also needs to be presented to the patient with understanding and empathy which is also beyond a machine.

The Hippocratic Oath

The Hippocratic Oath is the best-known legacy attributed to Hippocrates that is still used in the graduation ceremonies of many medical schools, albeit not always in its original form [7]. It represents an ethical code and a guide for medical doctors. Hippocratic medicine emphasized the importance of undertaking the oath in any era and area. The Hippocratic Oath advises the following:

I swear by Apollo Healer, by Asclepius, by Hygieia, by Panacea, and by all the gods and goddesses, making them my witnesses, that I will carry out, according to my ability and judgment, this oath and this indenture. To hold my teacher in this art equal to my own parents; to make him partner in my livelihood; when he is in need of money to share mine with him; to consider his family as my own brothers, and to teach them this art, if they want to learn it, without fee or indenture; to impart precept, oral instruction, and all other instruction to my own sons, the sons of my teacher, and to indentured pupils who have taken the Healer's oath, but to nobody else. I will use those dietary regimens which will benefit my patients according to my greatest ability and judgment, and I will do no harm or injustice to them. Neither will I administer a poison to anybody when asked to do so, nor will I suggest such a course. Similarly, I will not give to a woman a pessary to cause abortion. But I will keep pure and holy both my life and my art. I will not use the knife, not even, verily, on sufferers from stone, but I will give place to such as are craftsmen therein. Into whatsoever houses I enter, I will enter to help the sick, and I will abstain from all intentional wrong-doing and harm, especially from abusing the bodies of man or woman, bond or free. And whatsoever I shall see or hear in the course of my profession, as well as outside my profession in my intercourse with men, if it be what should not be published abroad, I will never divulge, holding such things to be holy secrets. Now if I carry out this oath, and break it not, may I gain for ever reputation among all men for my life and for my art; but if I break it and forswear myself, may the opposite befall me.

In these concluding words, the oath taker placed a malediction on himself, should he ever commit perjury; in fact, many oaths concluded with an imprecation against perjury. The Hippocratic Oath began with an invocation of deities and concluded with self-imprecations in the event the oath taker does not fulfil the oath or accomplish a life of glory, purity and holiness. In ancient Greece, perjury was considered a serious crime. Oaths were almost invariably sworn on deities, and perjury was regarded as a transgression against them. Therefore, the deities invoked would oversee the oath taker in medical practice and life; a person who upheld the injunctions of the oath would be granted fame and reputation, but a person who committed perjury would face a life of suffering and misfortune or a torturous afterlife [8].

We can only hope that when we become old and infirm our doctors have headed this lesson and act accordingly in our best interests and look after us effectively.

The doctor-patient relationship: a moral enterprise

The doctor-patient relationship has been and remains a keystone of care. This relationship has received philosophical, sociological and literary attention since Hippocrates. It is critical for vulnerable patients as they experience a heightened reliance on their physicians competence, skills and good will [9]. A robust relationship can guide decision-making treatment strategies in healthcare plans; therefore, this relationship has overlapping and conflicting interests between patients, doctors and healthcare plans. These interests may overlap to a greater or lesser degree depending on the actors and the circumstances. Standardization of practice is often used by healthcare to minimize costs and/or ensure quality of care, sometimes relying on evidence-based medicine. However, in the ‘standard of care’, what is good evidence and how that evidence should be applied is vague. Also, individual patients have individual needs and preferences that may be considered secondary or overlooked when following standardized practices [5]. The effort to cut costs means to increase competitiveness and profits and to see patients faster. In the end, both doctors and patients feel increased psychological pressure and industrial strategies withstand.

Doctors and patients should stand together and insist on standards that protect their relationship and healthcare plans. Relationship should focus on trust, reliability, advocacy, beneficence and good will. Physicians should not ignore the cost implications of treatments, but they should protect and act in favour of their patients [10, 11]. Similarly, healthcare administrators should not ignore the need for competence, compassion and individualization of care. Doctors should contribute to quality treatments guided by quality research, medical writing and publications to transfer knowledge. Patients should be educated about the potential of harmful practices in healthcare and should be informed and instructed on the applied treatment plans. It is prudent for plans to separate patients care from administrative rules and financial directions. Last, healthcare treatment plans should avoid business decisions that interrupt continuity between doctors and patients. To minimize harm, when these decisions are unavoidable, patient-oriented standards should be used, principles should be established and exceptions can be made [10, 11].

Overall, this could be utopia; various models of healthcare are co-existing and interfere in our current world. Basically, they all reduce to the old and unbreakable relation between the patient and his/her physician. We are not yet in a time where the patient could open an artificial intelligence terminal and interfere with the machine who could act like an expert system, making evaluations, prescribing exams and writing prescriptions [12]. The human is still in control of the machine [13,14,15]. One question for the moral side of the story is if the machine will be polite with the patients. Nice? Neutral? Empathetic? Express some humour?

In a futuristic world controlled by technology, the dehumanisation of the relation with the patients will probably be subject to moral and ethical concerns. As the Hippocratic Oath was made for human physicians, the future will see new laws rising for the machines.