The doctor patient relationship in team-based patient care

Is the doctor-patient relationship really more sacrosanct than the nurse-patient relationship?

That’s the provocative question asked by Theresa Brown in a recent column from Well, the New York Times’ health blog.

She discusses an instance when she had a disagreement with a physician over a patient care issue.

I couldn’t believe that this doctor, who had always worked well with the nurses on my floor, had just suggested, at least in my mind, that a nurse’s opinion on patient care matters less because patients don’t directly make appointments with us.

And she has a point. In a hospital setting, nurses spend significantly more patient contact time than doctors. Smart doctors will seek out a patient’s nurse and ask his or her’s opinion on how the patient is doing.

So, when she asks whether a doctor-patient relationship takes priority over the relationship between a patient and a nurse, the answer is clearly no:

Physicians have the ultimate responsibility for treatment decisions, but because nurses spend so much more time with hospital patients than doctors do, we have a unique view of how the patient is really doing. And at times, patients present very different faces to nurses and to doctors — complaining to a nurse in a way they never would to a doctor.

We are shifting away from a paternalistic model of care, and more towards a team-based approach. This is especially true in the hospital, where not only a doctor takes care of a patient, but also nurses, social workers, physical therapists, dietitians and discharge planners, to name a few.

Primary care, of course, is heading towards a team-based model as well — especially as accountable care organizations and medical homes become more prevalent.

So, instead of asking whether a patient has a good relationship with his doctor, it’s going to be more important to know whether he has a good partnership with his team.

 is an internal medicine physician and on the Board of Contributors at USA Today.  He is founder and editor of KevinMD.com, also on FacebookTwitterGoogle+, and LinkedIn.

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  • Annie Stith

    Hey, Dr. Pho!

    I like the way you end this post, referring to a patient having a good partnership with his/her health care team. The patient has to be a member of that team because… well… without the patient there’s no reason for the team to exist.

    I *don’t* like the statement in one of the quotes that “Physicians have the ultimate responsibility for treatment decisions…” Being an e-patient, I share that responsibility.

    I’m no longer dictated to by my doctor but, rather, discuss the pros and cons of different treatment options. Either we make a decision together, or I make the decision for myself, the “ultimate” decisions being to not treat at all or to find another doctor.

    Annie

  • http://www.healthecommunications.wordpress.com Steve Wilkins

    Kevin,
    In addition to physician-led team care, Medical Homes are supposed to be about “patient centeredness.” This basically means that providers should attempt to understand and, where practical, honor their patients preferences. I for one preferred being seen by the doctor not a PA or NP. I can see aspects of chronic care management being handled by team members such as diabetic educators, etc. But that really needs to be negotiated by the physician and the patient.

    Steve Wilkins

  • http://www.drdialogue.com Juliet K. Mavromatis, MD

    There is a difference between the nurse-patient relationship in an inpatient versus outpatient setting. In the inpatient setting this relationship is very intimate. Nurses spend entire shifts by the sides of their patients, doctors don’t. The health care team has been stressed as a key component of the medical home model in the outpatient setting. My concern is that this emphasis will become a mechanism to shortchange direct doctor-patient communication even more than it has currently become cheated by our 25 patient-per-day model of primary care delivery. Team-based care needs to emphasize continuity and improve communication between patients and their personal physicians and nurses.

  • stargirl65

    They have done some research on team based approaches to health care. They rated the same system before and after team based approaches to health care were instituted. The patients received more care in the team program and interacted with nurses, nutritionists, therapists, etc more often and sometimes their doctor the same or slightly less. The patients gave higher ratings before the team based care. They felt more connected and better cared for without the team.

  • Annie Stith

    Hey, stargirl65!

    You said:

    “The patients gave higher ratings before the team based care. They felt more connected and better cared for without the team.” (emphasis added)

    I can understand how this could happen with people who aren’t prepared to be e-patients or used to being treated by a team. I’d be interested in how the idea was introduced to them before implemented. Most people don’t do well with any kind of change.

    If this was an entirely subjective “feeling” kind of rating, I’d have problems with it. Kinda like those ads for women’s wrinkle remover, where they say more women “felt” like their wrinkles weren’t as deep and they looked younger.

    Annie

  • http://hippreservation.org/ Super Hip Chick

    Awareness of conditions, accurate knowledge, and access to appropriate care are three exceptionally important concepts to helping establish patients as active, engaged members of their healthcare team.

  • dspacl

    A couple of relevant edits:
    “So, instead of asking whether a patient has a good relationship with his doctor, it’s going to be more important (to the patient) to know whether he (the doctor) has a good partnership with his team.” -Just sayin’

    …Thanks for blogging on this one.

  • http://www.spokane.wsu.edu Barb Chamberlain

    Stargirl65, do you have a source citation for the research you describe?

    @BarbChamberlain

  • stargirl65

    Here is the reference. See bottom page S64 I believe under “implications.”

    http://www.usafp.org/PCMH-Files/AAFP-Files/Patient-Outcomes-at-26-Months-in-the-Patient-Centered-Medical-Home-National-Demonstration-Project.pdf

    “In other words, some practices improved their
    patient experiences while also implementing the NDP
    components, whereas the majority did not,”

    “Slippage in patient-rated primary care attributes
    after the NDP began suggests that technological
    improvements may come at a price.”

  • http://www.drdialogue.com Juliet K. Mavromatis, MD

    Several years back a meta-analysis was published by Shojania in JAMA looking at quality improvement of care for diabetic patients. Interestingly the study showed that team-based changes were most effective at achieving improvements in glycemic control in diabetics. Case management appeared to be particularly effective. Here is the reference: http://jama.ama-assn.org/cgi/content/abstract/296/4/427
    Clearly the care team can be changed to better support primary care delivery–particularly in the chronically ill population–but not at the expense of direct doctor-patient communication.

  • May Fran

    I completely agree with your thesis. Just returned from France where I spent 6 days in hospital and underwent 1 surgical procedure. I decided at the beginning of this experience that I would have a good relationship with everyone involved in my care, and, despite language and cultural differences, I received superb medical care from the entire surgical team- far above what I would have expected in a rural area in the US. (Won’t even get into the cost differential.)

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