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The Importance of the Doctor-Patient Relationship (and why we can’t have it anymore)
Why It’s Important
The doctor-patient relationship, I am led to understand, is still being taught in medical schools. But what they’re teaching is not the real doctor-patient relationship. It’s more of a Dale Carnegie thing — how to win your patient’s trust so you can persuade them to become more compliant to whatever program you devise for them. The real doctor-patient relationship has become so foreign to healthcare bureaucrats, and (sadly) to many doctors, that its meaning is all but lost in many quarters. In fact, to really explain it we need to resort to parables:
One day, down on your luck and in need of some quick cash, you decide to rob a Seven-Eleven. You rush in brandishing a 9mm, and order the clerk to hand over all the cash. He appears to reach under the counter, so you panic and shoot him. You quickly clean out the cash register and head for the door — where you run smack into two burly police officers who happen to be entering right then for some of that good Seven-Eleven coffee. You are quickly and none-too-gently disarmed and arrested. So there you are — caught red-handed, money in one hand, gun in the other, the blood of the clerk on your shirt, and for good measure the whole unfortunate episode recorded by a security camera. Now, here’s the question: What rights do you have?
Despite the fact that anybody can see how guilty you are, it turns out that you have many rights. You have the right to remain silent. You have the right to be considered innocent until a jury of your peers declares you guilty. And you have the right to appeal the verdict (assuming, of course, that you won’t like it).
But most importantly you have a right to a personal advocate, a knowledgeable professional who is obligated to defend you against all odds, to the best of his or her abilities; to place your vital interests above the competing interests of the community, and to help you navigate a complex and powerful legal system that is arrayed to punish you. Your attorney, whatever he or she might believe about your guilt or innocence, is obligated by law, by tradition, and by professional ethics to argue your case to the best of his or her ability, and, operating within a system of rules laid out by society, to leave no stone unturned in gaining the best possible outcome, not for society, but for you, the individual felon.
And while the rest of us might rail and complain against your lawyer’s attempts to get you off, we all understand perfectly well that attorneys must retain these obligations to their clients. We see that without such protections not only would accused citizens become horribly abused, but society itself would become coarsened and dangerous for everyone. And we shudder to think of the abuses that would occur if these protections were removed.
Sick people are no more capable of navigating the complex healthcare system than are accused felons the complex legal system, and are no less in peril if they run afoul of that system. And a patient’s need of an advocate, a professional whose job it is to protect the patient’s own best interests against the conflicting aims of the “system,” is no less vital than that of the felon. When you are sick, you should be entitled to at least the same protections as when you rob a Seven-Eleven. And the doctor-patient relationship is supposed to see that you are.
Over the ages the doctor-patient relationship has been defined, through rules of ethics and rules of law, as a fiduciary one, as a relationship founded in trust. When a patient seeks a physician’s help and the physician agrees to give that help, a special covenant is made. The patient agrees to take the physician into her confidence, to reveal to him even the most secret and intimate information related to her health. The physician, in turn, agrees to honor that trust, and to become the patient’s advocate in all health-related matters, placing her interests above all others — including his own personal or financial concerns.
Now, to be sure, the doctor-patient relationship was never completely pure in actual practice, not even in “the good old days.” But a strong fiduciary relationship has been what patients have expected, what most doctors have striven for, and what everyone else (the medical ethicists, professional societies, and those who write and enforce the laws of the land) have traditionally agreed — and even demanded — should be the standard. It represents the fundamental expectation of how doctors and patients are supposed to behave toward one another.
The loss of this doctor-patient relationship has obvious consequences for patients. Patients, when they are sick and thus least able to fend for themselves, are left without a true, dedicated advocate as they try to navigate the hostile halls of the healthcare system. Loss of the traditional doctor-patient compact leaves patients marginalized and floundering at the time they are most vulnerable.
Less obvious, but no less profound, are the consequences of a destroyed doctor-patient relationship to the profession of medicine. Abandoning that relationship means that physicians have committed the “original sin.” They have abdicated their traditional, ethical, and legal roles as patient advocates; they have broken a sacred pact. They have fully compromised themselves as professionals, and as a result, often to their utter frustration, find themselves standing naked before their enemies — the very enemies who forced this abdication.
Thus, the traditional doctor-patient relationship is vital to the professional survival of the physician, and to the physical survival of the patient. If doctors and patients lose this relationship, they lose everything.
Why We Can’t Have It Anymore
We can’t have the real doctor-patient relationship anymore for the very simple reason that the payer class (government bureaucrats and insurance executives) has identified the interaction between doctors and patients as the engine of all healthcare spending. To gain even a semblance of control over healthcare spending, they absolutely must control the behavior of doctors.
That, as they see it, is the entire answer. It certainly defines the whole theme of the Obamacare legislation, but controlling doctors’ behavior was well under way when Mr. Obama was still a state senator. (All Obamacare did was to introduce new methods for making doctors join the Borg; to make resistance even more futile.)
The particular mechanisms for usurping the efforts of doctors (forcing them to focus on maintaining their professional viability while staying out of jail instead of on their patient’s best interests) are too numerous to list. My recent post, an obituary for primary care doctors, named some of the main ones.
What most people — including most doctors — fail to realize is that the medical profession long ago capitulated. Because the realities of medical practice no longer allowed doctors to conform to their obligations to their individual patients, in 2002 the medical profession — represented by virtually every professional medical society in the world — formally adopted a “new code of ethics” that obligates doctors to work for “social justice.” (Because when it becomes too difficult to follow ethical precepts, you change them.) For the first time, physicians became ethically required to work for the collective good “in addition to” the good of the individual patient.
Virtually all commentaries surrounding this new code stressed that what’s good for the collective is also good for individuals. (This is just straightforward Progressive dogma.) So really, there’s no conflict at all. Doctors, not known for their grounding in ethical reasoning, generally did not argue too much. When they did argue, they were shouted down in a manner now familiar to climate change deniers.
The real-world ethical conflicts still occur, of course, and they occur frequently. But the precept of social justice gives doctors plenty of succor when they have to choose (consciously or not) to go against the best interests of the individual. When accompanied by expert-generated medical “guidelines” that direct them toward herd medicine, the social justice imperative leaves most modern doctors completely comfortable that they are doing the right thing.
To really reform the healthcare system in a useful way we need to understand fully the problems that exist in that system. And in addition to the grave economic problems healthcare poses to our society, the ethical problems are perhaps just as bad, and may turn out to be as intractable. We will have to take the broken doctor-patient relationship into account as we go about fixing things.
Or not — in which case we will not like the results of our efforts.
Published in Healthcare
Liberals are all about destroying privater personal agency under the guises of protecting the consumer. In relativity all stances we get in multiple industries from Finance to Lawyers is a degree of separation were know one has personal responsibility with real consequences of violating their agency for that person. There are so many layers with responsibilities being so distributed everyone can pass the buck and not really get their hands dirty by being on the ground. A system needs to be were a vast majority of decisions are done by professionals who have personal liability and can’t pass the buck to the goverment, corporations or some other person.
This is a fair assessment of the breakdown in healthcare. Doctors are prevented from providing individualized care and perhaps more importantly are now required by law to ask intrusive questions and report back to the state (do you own a gun?). The trust relationship is inherently changed: it is a three-way between you, your doctor, and the government that controls your healthcare. Worse, it could even be considered a four-way: include your insurance carrier in the equation.
Don’t have to answer, truthfully or at all. yet.
It’s a good thing my doctor has never asked this question. My answer would not comply with the Ricochet CoC.
It seems like you are advocating a new player in the mix: the health care advocate. A kind of lawyer that takes your personal interest in matters dealing with the health care system.
It’s like when my wife and I were navigating the insurance miasma when she was in a wreck. The insurance company was all nice and helpful until their liability was going to exceed the coverage limits, then they turned on us and wanted to make us fully liable. We ended up having to get our own lawyer to help us persuade the insurance company to keep their end of the bargain.
If the health care advocate does become a thing, I can see the doctor patient relationship becoming adversarial quite quickly. With discovery to uncover actual services performed and procedures followed; much like a malpractice suit, but much faster after the fact or even during the fact.
I am indeed. Too bad what’s happening to the doctors, but that pales compared to the risk faced by sick people. Unfortunately it’s going to take a lot for doctors to get enough backbone to face their oppressors and regain the classic DPR. The way it looks to me, if the patients are OK with the current state of affairs, doctors will be, too.
When patients begin hiring their own private advocates (and such people do exist), that might wake up some doctors at last. And if it doesn’t, well, at least patients will have access to some personal protections before the damaging medical decisions are made, instead of just afterwords.
Asking about firearms is becoming an increasingly common item on doctors’ pay-for-performance checklists (for which making the right checkmarks is critical to a doctor’s long-term viability). So better prepare your non-CoC speech. You may be needing it.
The old guard of patients will too soon be gone and the current will be thought of a normal.
I have a colleague whose 92 yo mother (we’ll call her IB) was a nurse. A couple of years ago IB goes to meet her new doc, her previous one having retired. This appointment was supposed to be some sort of physical in addition to a meet and greet. When the appointment was over IB noted to young doc that he hadn’t touched her during the physical. His reply was that were taught (told?) not too cuz they might get sued.
I think it’s still OK for doctors to touch patients if they get a triply notarized statement (vetted by a team of lawyers) that consent was duly sought and freely given. I’ll admit that I might be a step or two behind on the current guidelines on this topic though.
Perhaps if doctors were certified by the TSA (and why not, as they need certification from everyone else) they could touch anybody they want.
I didn’t get that particular question when I was shopping for a doctor to replace the one driven out by ObamaCare, but I think I got the one about whether I feel safe. I wrote something to the effect that it wasn’t relevant to the medical care I was seeking. Nobody who looked at my forms batted an eye, as far as I could tell.
I was thinking “No, your office scares me a bit.”
@drrich, I posted this a few weeks ago. Would giving Medicare, Medicaid and VA patients HSA cards (and charging them monthly with money) help?
They are required to ask those questions. Many doctors offices are rebelling in the few ways they can: by not paying attention to the answers. Safety is relevant due to the rates of domestic violence and mandatory reporting. Since doctors don’t often actually do their jobs (they are paid not to!), it helps if people directly tell them that they are being abused so that they can receive help. I mean, it’s not like abusers obsessively look over their partner’s papers and medical appointments and ensure that all of the stories match…
Yes, I agree. I and many others have also proposed healthcare reform plans that rely on some form of HSAs, at least as a critical component. I also agree with you that full or partial funding of the HSAs with tax dollars would be needed for many citizens, if not for everyone.
Which is the sad part.
I have had such rocky relationships with doctors over the last 8 years and it sounds a lot like what you describe.
The last 8 years have been filled with treatments with no clue who I am. I have been treated as a clueless first time mom while symptoms of hyperemesis went undetected. I also had a doctor respond to my claims of fidelity to my spouse and he to me with “better safe than sorry.”
I am outside the medical community but am not stupid by any means, so to have been treated so poorly by the people entrusted with my care has been baffling and frustrating.
I threw up for 8 months of the 9, but since I didn’t lose weight, it was considered inconsequential. I also had my pelvis separate resulting in lots of pain and a fun clicking sound whenever I walked (this began early, maybe 5 months in). I was never asked about my partners’ fidelity, but was surprised later when it turned out he was a cheater. I would have rather had routine testing than having to rush out when it turned out that my boyfriend spent quality time in China cheating on me (which he lied to me about for over one year).
It does not sound very nice, but it is better safe than sorry. Also, unless you were both virgins, there’s a chance you could have occult HPV. You never know.
Sometimes fulfilling the DPR means asking difficult questions, and not all doctors use diplomatic language. However, if this was the same doctor who missed hyperemesis gravidarum, a very serious condition, a lack of diplomacy may be the least of his/her professional difficulties.
My wife had kids have a PA as PCM now (your last post was about that I believe), and I only have an MD for my PCM because the timing worked out that he was new at the office when I decided to get fat enough to have hypertension that requires management. At one appointment with him I said something snarky about the state of medical care (likely because I had recently read a post like this), and I could see how much my doc was biting his tongue to keep from agreeing with me about how far things have fallen. I think many doctors see the same things you see, but I don’t know what if anything they can do about it. What takes the power away from them in this? When he told me to try a Mediterranean diet (telling a guy with the surname Patrick to not eat potatoes is just silly) was that to check off another box on another form? Clearly, having a relationship with me would drive a more realistic recommendation.
If mandatory questions become common enough, patients will become suspicious of even those related to health. Without trust, physicians won’t get all the facts and both will suffer for it.
I believe that is a main point of the post. It takes time and involvement between parties to develop a relationship and trust, and the way the system works now it seems designed to thwart such a thing.
Third party payment.
Dr. Rich,
A good post, but missing a key element:
The lawyer analogy is apt. However, outside of public defendants and the rare pro bono case, most normal citizens cannot afford to keep a lawyer on retainer at the level we desire from our primary care physicians (i.e. one or more hours per month, plus intensive effort on a semi-regular basis). Indeed, it is only the upper-third of the income scale that can afford such a relationship with their lawyers.
If we took the state out of the equation, there is a real possibility that a large chunk of society – perhaps even a majority – would not be able to afford the type of doctor-patient relationship we all yearn for. And understandably so: that type of relationship requires time and effort by a highly-trained professional. That doesn’t come cheap in anyone’s free market fantasy world.
So we have a Faustian decision to make: should we restore the sanctity of the doctor-patient relationship at the risk of it becoming out of reach for millions of people (including those who would be most vulnerable without such a relationship)? Or do we have the state provide it for everyone – with the inevitable conditions that the standard of care will be poor and politics will creep in?
I don’t think it’s an easy decision.
It is my understanding that at least 1/3, if not half, of the cost of running a family/primary/internal medicine practice is overhead. I’d bet that the lion’s share of that overhead goes to paying staff (or outside sources) to bill, collect, chase down, etc, payment. Take that out of the equation and the price goes down considerably.
One of my coworkers has a side business where he contracts with medical providers to harangue insurance to actually pay claims. Apparently this is a growing field as insurance can easily deny a claim falsely and roll the dice that the provider won’t resubmit within the required time frame.
But considering that the true (i.e., unsubsidized) current cost of primary care is hovering somewhere around “exorbitant”, a drastic reduction in costs still doesn’t guarantee that it would become affordable for the lower third of earners.
We’re still talking about the type of transaction that remains expensive in any free market situation: a highly-trained (and hopefully experienced) professional who is expected to spend quality time on his client – including when the client isn’t present – on a very regular basis. That type of effort will never be cheap.
I agree that in a world unfettered with useless regulations, overhead, forced cost-sharing, and administrative bloat, many more citizens could afford productive doctor-patient relationships than is currently the case.
But it would still be far from 100%. And we, as a society and even among the political right, cannot bring ourselves to admit that in order for the free market to bring down prices in healthcare, some people may have to be priced out of care we consider to be “necessary” care (such as having a reliable and accessible primary care physician).
So we bend over backwards to provide that missing 20 (or however large) percent with some semblance of healthcare, with the result that it becomes more expensive for everyone, and another 10% get priced out – leading us to subsidize it for that 10% as well, and thus unleashing an endless vicious cycle of cost inflation.
The payer class is right, though. The doctor-patient relationship is the engine of all healthcare spending, and always has been. The core of our dilemma is the expansion of the payer class from just the patient and private charity (including the doctor himself) to include employers and government.
Modern medicine is so competent that aggregate demand for it far outstrips any economically possible supply, especially in regards to life-extending care for the aged. A doctor advocating for one’s patient in a traditional resource-limited situation promotes solutions (if any) that fit those resources. Today, doctors are expected to advocate for their patients without regard to the limits of other people’s money. Which truly is unsustainable and unethical. Ergo, a rewritten ethical standard.
Creating a class of lawyers to solve this problem is just another layer of bureaucracy siphoning off resources (other people’s money, again) that should be spent by families on their members. No thank you.
Where did their power go? Long gone. Most doctors have lost the ability to determine their own professional viability. They must rely on third party payers to bless their every action. And if they admit patients to a hospital or perform any kind of procedures, they rely on retaining their privileges to do so — which means keeping bureaucrats satisfied.
Re: Mediterranean diet. This is the diet that currently has the best data behind it in terms of reducing cardiovascular risk. Whatever his motivation, he was giving you sound advice. That he took the time to do so, despite your name being Patrick, is a sign that he takes his job seriously.
While medicine has gotten dramatically more effective in the past 50 years (there was just so much a doctor couldn’t do even 30 years ago for relatively common ailments that now have fairly common treatments), this has caused the amount and price of medicine to dramatically increase. We shouldn’t do much about the amount of health care we as American’s consume, but we can do something about the price.
It used to be that doctors and hospitals practiced a lot of pro-bono medicine and services for barter that allowed low income patients to get the basic medical services they needed without spending a lot of money. The cost of the primary care physician is minimal, it is the cost of reporting every 15 minute visit to the primary care physician to the insurance company so that it can meet one’s deductible that is the problem.
I would like to see the statistics, but I would bet that the number of doctors and nurses are far outnumbered by the billing and administrative people that work in health care (this includes people at health insurers).