How can we fix the doctor-patient relationship?

A post I wrote nearly three years ago has recently gone viral, bringing tens of thousands of readers and a huge number of comments.  It’s a letter I wrote to my patients who do something that all but guarantees a bad relationship with many (if not most) physicians: they don’t get better.

There are basically two responses I get to this post: either readers are grateful to have a doctor admit to our flawed humanity, or they are furious that I would suggest that patients, the ones with the disease, should see physicians as needy and flawed humans and therefore watch how they act around them.  If you haven’t done so, read the comments to this post and hear the deep frustration and anger brought out by a letter that sympathizes with their pain and (apologetically) tries to help.

Amidst the dichotomy of reactions, both of which I understand, is the obvious question: why has a relationship that exists for the purpose of healing and helping become one of frustration and anger?  The corollary to this question is perhaps more important: what can be done to heal this broken relationship?  A reader of my last post (about viewing patients from a different perspective) asked me point blank: “Dr. Rob, for the 99.999% of us who do not have a primary care doctor who is thinking as progressively as you, what advice can you give so that we can get our doctors to be treating us in the manner in which you are treating your own patients?”

I must admit, I get a bit uncomfortable with this, as it sounds like I am putting myself above my colleagues morally. Ironically, it is my deep understanding of my own huge flaws, coupled with an upbringing that scorned conformity, that rips me away from the survival self-centeredness most docs eventually adopt.  Putting myself on any moral high ground only invites a very public (and deserved) fall back to the low ground I usually inhabit.  No, I’m also not putting myself down out of false-modesty; I’ve made peace with my flaws, embracing them for what they are: a lens with which I can understand my fellow human scum-bags.  Of course, as my best friend (and best man) used to remind me: “remember, I am doctor scum bag to you.”

Now, I don’t lay the whole problem at the feet of the fallen nature of mankind.  I believe that our system of health care doesn’t just fail to counter the flaws of our nature, it actively promotes bad relationships.  It does this by:

1. Reducing patients to problems. The payment system requires we use “problem codes” to classify patients and justify visits.  The problem-oriented approach is not just a byproduct of the payment system, though, it is at the very core of medical education.  Despite a 100% ultimate failure rate, we are still taught that death and disease are the opponents we need to outsmart or out-procedure.  Perhaps its analogous to the public infatuation with the tawdry and grotesque (the more gruesome the murder, the more news shows cover it), but we physicians love “interesting cases.”  But nobody ever wants to be an “interesting case.” Ask any of the people who commented on the blog post.  Boring is better.

2. Rewarding sickness.  Having a full office pays the bills.  If everyone got healthy, the system would collapse.  This means that anything that would help patients get healthy stands against the financial well-being of doctors and hospitals. If doctors communicate poorly with my patient, they will be less likely to get well, and will hence be more likely to need their services.  I don’t think docs actually use that sickening logic, but it is the ugly truth about our system.  This is why tools that should make care better are not adopted: doctors are penalized when they improve care.

3. Making doctors targets.  I am not talking about patients, I’m talking about payers targeting physicians (and hospitals) as the cause of the problem.  It would seem that the best strategy to fight unnecessary cost would be to simply stop paying for unproven, unnecessary, and/or harmful procedures.  Better yet, why not pay docs like me who are motivated to keep patients well and happy?  But payers instead target doctors through small financial rewards and huge sanctions.  ”Quality measures” are not out there to reward high quality, their purpose is to expose and shame the bad doctors and hospitals.  Am I exaggerating?  Perhaps; but I can say that one of the best parts of being out of the insurance-oriented system is to no longer feel the passive-aggressive eye of big brother waiting to catch me not following their rules.  All docs feel this, and it puts them in a position of defensiveness, which is not good for patients.

4. Killing time.  One of the most remarkable differences in my new practice is the amount of time I can give each patient.  I can answer the phone and handle their problems.  I can sit and chat with them if they stop by to pay their bill.  In the old system I was always late, always pressured to move on to the next patient, and rarely had time to do the most important thing: communicate with my patients.  Good care takes relationship, and relationship takes time.  Nobody has time any more because the system seeks and destroys time, either by filling it with meaningless clerical tasks or by punishing those who take extra time with lower pay.

In our health care system we have a business where both ends of the transaction are miserably unhappy.  99% of doctors hate the health care system, and the 1% who like it are the ones to avoid.  Patient dissatisfaction is nearly as high, skewed downward by people who have grown so used to the terrible system we have that they now see “terrible” as “average.”  Is there any other business where both consumer and those providing the product are so unhappy?  The reason for this is that someone else is shaping the system: the payers.

I must admit, I am not sure how this can be fixed in any way other than a total disruption of the current system and replacement with one that is centered on people, not problems, on communication not documentation.  Until we have a system that doesn’t reward sickness, sickness will be the reward we reap.  I left the system because I didn’t think there was any way to continue practicing good care in it.  While my new practice is far from perfect (consider the source), at least I am rewarded for taking time with people.

To have any chance at building better relationships between doctors and patients, we need to face the painful reality that our system corrupts even those with the best intentions.  So, I guess that would make it a “scum-care” or “health-scum” system?  The sooner we face our ugly reality, the more the chance of bringing the focus back to where it should be: caring for patients.

Rob Lamberts is an internal medicine-pediatrics physician who blogs at More Musings (of a Distractible Kind).

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  • trinu

    A good start would be letting patients see their primary care physician, instead of shunting us off to the midlevels with the “patient-centered” medical home. It also wouldn’t hurt to put the decision-making in hands of patients and their physicians, rather than insurance company bureaucrats.

  • Natasha Gajewski

    Communicate at eye level.
    Repeat back what the patient says to ensure understanding.
    Summarize what the problem (diagnosis) is/may be.
    Describe, justify and ask for agreement in pursuing next steps.

    Common sense.

    Allow me to add one more: task the patient in some way that dignifies his/her role as a team member rather than an object to be acted upon. Add weight to the responsibility by identifying a follow up action and date. This gives us patients a sense that we DO have some power, some autonomy, some dignity.

  • Wy Woods Harris

    I became an Advocate for cancer Patients and their communities after spending 45 years as a health professional watching Doctor Patient Interactions. I now believe that my training in Listening is my best work to give back to this community of patients.

  • anon3

    Maybe doctors should just pay attention?

  • Kaya5255

    Physicians who treat their customers as if they were second class citizens are the crux of the problem.
    Paying customers have the right to be treated with respect. It begins in the waiting room where the subordinate role is reinforced when customers are addressed by their given names and the provider is referred to as “Doctor”.
    It has been my experience that physicians are threatened by knowledgeable and assertive customers. Physicians want to call the shots and dismiss customers who question the medical necessity of prescriptions, tests, etc. Any one with the Intranet can read the same journal articles that their physicians do.
    I use the defination “customer” for a reason. I pay and I have no patience!!

  • Guest

    Mutual respect and shared responsibility. Both parties apologize for their mistakes and try to do better.

    Each respect the other’s time…acknowledge and apologize for keeping one another waiting, but each also recognize there may be valid reasons for running behind schedule. I don’t believe the doctor’s time is more valuable, but it is often more critical because of all the unexpected things that can come up during their work days. If I’ve waited for a long time, the doctor needs to understand I may have run out of gas due to fatigue from my illness (i.e. I might go off track or be less coherent during the actual visit). On the other hand, I’m glad to wait extra for my doctor rather than have him/her skip yet another meal or bathroom break. Any of that basic upkeep that we all do to stay alive and functioning…I can wait. :)

    I’m kind of old-fashioned and don’t really see myself as a customer. And not only because of the complications brought in by third party payment. There is an aspect of the relationship that’s like business/customer, but it goes beyond that. When people are really sick or hurting, the “service provider” model just doesn’t cover it.

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