In ancient Greece, the school of Knidos based medicine on facts, whereas the school of Kos based it on empathy (8). Empathy is difficult to teach and hard to learn, as measurements on the Jefferson scale have shown (9). In essence, empathy as an evolutionary advantage is inherited (10) – although it can be modulated by biographical and situational factors (11).

Modern brain imaging of mirror neurons and the theory of mind demonstrate how empathy can be visualized (12). Neural imaging has also revealed that some individuals behave altruistically more than others (13). Some express social competence; others appear callous (14). Alarmingly, altruism and aggression might represent only the extreme poles of a neuro-humoral continuum (15).

Empathy is personal at its core but must not be mistaken and equated with sympathy (11). With emotional distancing, the factual approach at first sight might outperform personal affection. However, the clarification of the conflictual nature of a personal patient-physician interaction will establish the required emotional distance.

Emergency and technical medicine targets maximum quantity, often accepting average quality of results. Such factual medicine needs prioritization; and the conflict between utility and futility compels for debatable decisions (16). Codices regulate that physicians’ profiting from the patient’s emergency will undermine trust and is not compatible with physicians’ fiduciary responsibility in court (2).

The factual patient-physician relationship is necessarily based on confidence. Patients must trust in the physician’s competence and physicians need trust in their findings. Thus, invasive investigations must establish a reliable diagnosis. In order not to undermine patient’s confidence, advanced therapy might follow even without a reasonable prognosis or, worse, even where merely a palliative approach is indicated. Thus, factual medicine can result in overtreatment.

In contrast, the personal patient-physician relationship relies on responsibility (17). Responsibility is associated with disclosing the facts. Considering the patient’s whole history and all physical presentations produces insights. Insight requires less laboratory and less technical-diagnostic work; it makes untargeted and costly examinations superfluous to establish diagnosis and therapy. Thus, the personal relationship generates a resource-efficient method of diagnostics and treatment.

The respect of autonomy is a modern achievement and this applies equally to patient and physician (2). According to the traditional and essential precondition of the patient-physician relationship, however, the interests of the patient should always come first, and the interests of the physician are legitimate but secondary (18). This assertion no longer applies in the formal patient-physician relationship, where both have equal rights jeopardizing the essential precondition of the patient’s primacy. In consequence, the currently spreading extreme of the formal model is commercialization (19).

The personal relationship is dyadic and discourse ethics constitute the procedural rules of respect, dialogue and consent (20). Through deliberative arguing, the shared decision-making process seeks an Habermasian paths of communicative action, whereas written informed consent asks only for the fact of an unrestricted yes or no. In the personal relationship, the physician does not simply deliver medicine – the physician embodies it. A sublime anthropological mechanism makes the physician seek a cure: Suffering or welfare on the patient’s part will correspondingly produce defeat or triumph on the physician’s part.

The patient and physician are not friends (21). The patient-physician relationship is based not on amity but on a specific purpose, as already recognized by Plato (427–347 BC): This purpose is life and health, not the other person [Lysis 218d – 220b]. The physician must critically question what the patient presents to find the hidden secrets and see through, for instance, the mystery of non-adherence (22). The personal relationship makes the physician an enemy of the patient and the patient an enemy of the physician; patients intend to defend their integrity, but the physician’s actions are invasive.

By examining the individual history and touching the real body, physicians offer the personal relationship. Which relationship fits best is not up to the discretion of the physician alone and is not up to the discretion of the patient alone. To succeed, physicians must practice the culture of a controversial dispute in the personal relationship from the beginning.

Disease is the adversary of both the patient and the physician. In fact, sick persons are enemies to themselves. The disease cannot be separated from the afflicted person; it cannot be attacked without attacking patients. By fighting the disease, the physician must combat the patient, who “does what the disease compels him to” (23). The more irritated by the course, the more patients will live in their own, disease-formed individual reality that encloses the patient like an “invisible cuticle” (24). Patients build subjective theories to protect their personal view on life and the world. Such theories represent parts of their mental survival strategy. What may objectively be judged a lie may subjectively sound to the patient like a plausible interpretation of what is happening to him or her.

Patients try to form a theory of the disease that relieves them not only of suffering but also of responsibility. Patients can repurpose illness to excuse and liberate themselves from external or internal obligations and pressing expectations. This social and mental relief imbues illness with a magical, seductive power. Patients try to locate the origin of a disease externally in the environment or to ascribe it to other persons. Typically, however, the exogenous alcohol does not cause it – the endogenous addiction causes the disease.

The disease is a product; it is created like an artwork. Disease is inevitably a part of the patient, and patients unconsciously identify themselves with their creations. The physician can heal the patient only through – metaphorically speaking – amputation of the disease. The patient-physician interaction will encounter interpersonal conflicts resulting from inherent contradictions of the patient’s own interests. These conflicts should be deconstructed by two sides: the patient and the physician. Familial and social bonds can contribute to inner conflict solving; often, however, they are also the reason of such conflicts (2).

The personal relationship activates and empowers the patient to fight the disease. Empowerment of patients, however, results in the logic of competition (25). The patient and physician must fight rather than appease each other. Self-esteem prompts the patient to compete with the physician. This is also evident in the saying “medicine tastes bitter.” Similarly, medicine is not a game: it provokes aversion.

In a factual, formalism-based relationship, the physician aims to relieve symptoms and to comply with requests, as demonstrated by the US opioid crisis (26). In contrast, the personal relationship fights for a cure: The physician seeks to win, to defeat the disease and to heal. Thus, the physician must attack rather than appease.

The disease exposes the patient to the existential threat of annihilation, just as it exposes the physician to the existential risk of personal failure. When the patient is an adversary, the physician instinctively seeks a cure to render such personal risks unnecessary. When the patient is a customer within a value chain, the physician seeks a type of treatment that continues the clientship. This meets with the patient’s sublime resistance to any expropriation of his/her discharge-like retooling of the disease.

Patients might feel ambivalent about a medical cure that liberates them from threats but re-exposes them to interpersonal and existential demands. The personal relationship also exposes the physician to deep irritations, even harboring potential risks to the physician’s self-confidence and self-esteem. The risk of interpersonal war’s absurdities (19) must be prevented by flexibly shifting from a personal to the strictly factual mode of interaction.

The personal patient-physician relationship considers each patient as a new and special case. In the factual relationship, however, the patient is a representative of general knowledge. Rational thinking underlies both the technical and personal approach to patient care, but the logic differs between symptom-oriented and patient-oriented approaches. Whereas the factual relationship applies technology, the personal relationship applies science. Guidelines and standard operating procedures might protect against neglect, but they can distract from personal engagement.

The personal relationship requires a clinical scientist to individualize medicine. The personal encounter follow a cognitive timeline spanning past, present and future. The clinical practice resembles an epistemological process like a doctoral thesis. According to Michel Foucault (1926–1984), it was not until the 19th century, “that such medicine was borne that is science of the individuality” [BoC. 1973. Epilogue]. Diseases are rule-based entities – otherwise, medicine as a science would be impossible. The disease identified does not differ from textbook knowledge, but patients make them appear real in their own different and individual way.

As medical scientists, physicians need to rediscover and reinvent how they can apply general knowledge to the individual case. Precision medicine looks at the facts, while individualized medicine looks at the person. The personal approach considers all findings of the individual, not just precise and measurable findings.

Physicians make mistakes. In this context, Michel Foucault stated, “physicians learn more by their failures than from their success” [BoC. 1973, IV; 5]. Consequently, in a factual relationship, any fault must be adequately compensated, whereas in a personal relationship, failure must be communicated. Again, patients and physicians are not friends. Compensation, however, means money, whereas communication seeks a medical solution.

Ethical competence stands above moral obligations, as discussed with respect to the dilemmas of truth telling, abortion, or terminal sedation and brain death (17). The personal relationship, more than the factual relationship, therefore, is associated with ethical stress (16). Patients can exert moral pressure thus potentially exploiting the physician’s ethical attitudes (Figure 1).

Physicians will deliver high-stage ethics and grand epikeia, a place above the law, only in singular cases. Supererogation can be expected at the personal, not at the formal level. Conversely, the higher the moral pressure exerted by the patient, the lower the stage of ethical response by the physician, ultimately becoming defensive, purely legal and factual. Moral pressure and the potential for exploitation indicate yet again that the patient is not the friend of the physician: “the patient is the enemy” a nephrology fellow once stated. However, the same ethical principles apply to an enemy as to a friend.

Patients may feel comforted when physicians act like a substitute for their mother or father. Such a feeling constitutes an anthropologic motion for the personal relationship with physicians. The more dramatically the conditions deteriorate, the more urgently physicians are expected to represent an almighty savior granting eternal life.

Unaffected by familial expectations and transcendental projections physicians must confront the individual reality of the patient with the objective reality. Carl Friedrich von Weizsäcker (1912–2007) reminded the lay public that the “biological purpose of a disease is ultimately to make the individual organism die” [AoP. 1977. I, 9.]. In contrast to the biological purpose (=causa finalis), the biographical meaning of sickness is an unpleasant appeal (=causa efficiens): The patient should change something, either lifestyle, workplace, relations, or attitudes.

Modern medicine opens a global perspective of unprecedented possibilities. For an individual, however, the future prospect narrows by each day that passes. A factual relationship causes the discrepancy between common sunrise and private sunset to be forgotten – not so the personal.