The covenant between physician and society is being broken

I have often spoken of the doctor-patient relationship as a covenant. Our patients bear their bodies and souls in exchange for a thoughtful, engaged, respectful partner in navigating health and disease. This dyad, this trusted space, allows for the breaking of cultural norms and full disclosure.  Proper healing is an agreement, it is a relationship.

Although often not spoken of, any successful flourishing health care system also requires another sort of covenant: one between provider and society.  Let me explain.

Being a physician has changed me. For someone who naively went into this profession hoping to help people, the reality is much more nuanced and difficult.  I make decisions hourly, daily, that have a profound affects on people’s lives.  As a mentor once told me, each successful physician has a graveyard full of patients with their name on it.  While I am not that cynical, I have no doubt that even with the best of knowledge and skill (and following medical guidelines and standards to the fullest), people have died by my hand.  I am not proud of this.  The thought keeps me up at night and wakes me early in the morning.  It literally turns my insides.

I have to live with this.  Day in and day out, my decisions, treatments, or lack thereof may have immediate and devastating consequences.  There is no other profession with such a dyer moment to moment routine.  Policeman and fireman spend just brief seconds of their career making such split second decisions.  Judges, lawyers, politicians, even air traffic controllers rarely deal with these imminent vagaries.

This stress, this fear, breaks us.  It can turn the unlucky into a cold shell of a person, a far cry from who they used to be.  Those who are introspective enough to recognize PTSD can, with the right struggle and support,  learn to once again become effective, emotional human beings.

Being a physician takes it’s toll.  Not just on our psyches, but on our relationships, on our children.   In many specialties the ring of the phone is incessant.  Government regulations have become so strict that every time a patient scratches themselves, a physician gets a phone call. Birthdays, anniversaries, vacations, and graduations have all been interrupted.  And what is one to say to the poor patient or family. Sorry I couldn’t answer the phone to help your poor dying husband, I was at a birthday party?

The hours are difficult.  The work is arduous.  And many more battles are lost than won.

But there is a silver lining, a saving grace.  Along with the above outlined struggles comes something, that for many of us, makes it worthwhile.  Many of us will gladly exchange the heartache and pain for what we believed was our due when we went into medical school.

Respect. We expected that society at large would understand the sacrifice of being a physician.  The hours, the culpability, the stress.  That instead of pointing a finger at us, blaming us for the financial downfall of our system, or beckoning us to defend ourselves in court, a hand of solidarity would be extended much as we try to do for our patients.

Compensation. The idea was that a physician would be provided for commensurate with the amount of hours and difficulty of the work.  This work, a calling, should garner enough income to keep the lights and heat on.

Meaning. When governmental regulation and intrusion becomes primary, we have lost our way as a society.  Physicians derive meaning from taking care of patients, trying to heal, and comforting.  The flurry of paperwork, meaningful use drivel, and insurance hurdles leave no time for the best part of our job.

This is the covenant I speak of between physician and society.  Physicians will do arguably one of the most difficult jobs in the world in exchange for respect, reasonable compensation, and the freedom to use their skill in meaningful ways.

Dr. Aaron Carroll believes that some physicians are crying wolf.

I believe the Medicare data dump, meaningful use, and the SGR mess are signs that the covenant has been broken.  Maybe physicians are not dropping Medicare yet, but they are retiring early.  They are choosing specialties outside of primary care.  They are emotionally divesting from their lives work and leaving the patient confused and unsupported.

They are turning their pagers and mobile phones off when they leave the clinic, and letting someone else handle the mess.

Jordan Grumet is an internal medicine physician and founder, CrisisMD.  He blogs at In My Humble Opinion.

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  • ninguem

    Dr. Aaron Carroll believes that some physicians are crying wolf.

    So, I followed the link

    “……As an academic general pediatrician, I cry BS…….”

    No credibility, right there.

    The academic setting allows the docs to charge multiples of what the private docs are allowed for the same work. In Oregon, the medical school has malpractice protections, was shielded from malpractice reporting rules, some of this was taken away because, frankly, it was abused. They used to use the state tax collectors as their collections agency for nonpayment, I wonder if they still do that. What would happen if I used IRS-like tactics to collect from nonpaying patients.

    Do general pediatrics in private practice. Learn certain realities.

    Then we’l;l talk.

  • SteveCaley

    Vocation is a term used in Catholic circles about the dignity of one’s labor, and being called to a certain occupation. Usually, one hears it in terms of religious orders, but it also has the term “lay vocation” used for the professions. There is a concept of a spiritual core to a person that brings them to a particular type of work.
    That is certainly not the spirit of today. Each “job” is merely a polished and boring thing that you do. The individual items that pass by you on the treadmill are meaningless, nameless.
    We wonder how that happens – but we, society, does it to our very selves. We tolerate impersonality – and we reap its whirlwind.

  • querywoman

    Covenant? Not in my lifetime!
    A “covenant” would mean that I have the right to go to a doctor, describe my symptoms, and get treatment instead of being hucked into preventative screening!

    • Teresa Brown

      I’m not exactly sure what it is you’re dancing around here. You’re treated based on what your doctors feel your diagnosis is, not what you want.

      Preventive medicine helps keep you from going with undiagnosed serious illnesses like heart disease, certain cancers, etc. Preventive medicine does not mean hucksterism.

      • querywoman

        I’ve walked out with nothing most of my life for my skin disease. Arthritic pain, which was related to overwork on computers, was also blown off and ignored.
        Yes, I know for a fact that most doctors treat only on what they think a diagnosis is. And also spend a lot of time hucking preventive tests.
        When I am paying the bill, I have a right to get treatment for WHAT I WANT including real illnesses with visible symptoms.
        I can’t count the times when I’ve gone to emergency rooms for illnesses doctors ignored. And all the times when I had to pay another doctor, and many times lots of doctors, to treat what someone else ignored.

      • querywoman

        Here’s another jewel for you, Teresa Brown. Suppose a patient walks in to a doctor’s office, drops down good money to discuss what the patient wants, and the symptom gets ignored while the doctor has a blood pressure rant.
        This is a terrible way to motivate a patient to take blood pressure medicine.
        It’s such obvious misconduct.

        • Teresa Brown

          Misconduct? Not even close. Misconduct is fraud; being impaired while seeing patients; running a “pill mill” out of the office; assaulting patients or hospital staff, etc.

          If the blood pressure was high, the physician had an obligation to address the issue; it would be unprofessional to do otherwise. What good would it be to treat your skin condition/arthritis if your blood pressure was high?

          Physicians, and other health care professionals, need to prioritize, so certain conditions are going to trump others; hypertension rumps arthritis or skin problems. The patient still could have brought up the issue s/he thought was important to her/him after discussing the blood pressure. Threatening to be non-compliant with BP med regimen because the patient didn’t get to drive the appointment is childish.

          I’m assuming we’re talking about you here. Well, suppose your doctor had done what you wanted: ignored the blood pressure issue and focused on your skin or arthritis. If you’d had a stroke, would you have still been OK with him not addressing your BP?

          It’s a shame that you see preventive medicine as nothing more than hucksterism. Preventive care has been proven many times over to have saved millions of lives.

          Health care is not like a trip to Burger King: you can’t always have it your way. If you are so dissatisfied with your primary care doctor, perhaps you’d be better served by getting your care from another physician.

          • Teresa Brown

            Why not go to a dermatologist for your skin problem?

          • querywoman

            I have a decent dermatologist now. I can’t even begin to list all the ways the lifetime of neglect of my atopic eczema has impacted my life.
            I feel confident that there are many other illnesses that get neglected while doctors diddle around with the blood pressure cuff, read cholesterol tests, and huck cancer screening.

          • Teresa Brown

            That’s interesting…reserched me how?

            In any case, I wish you well in you quest for a doctor who satisfies your needs.

          • querywoman

            I researched your Disqus comments.

          • querywoman

            I researched you and see that you are a nurse. You are talking a classical medical line.
            The best way to handle the situation would be to come in and start talking FIRST about what the patient chose to pay money to discuss, then to work into the blood pressure.
            Would a heart attack or stroke happen in twenty minutes?
            It is never appropriate to IGNORE what a patient. That is MISCONDUCT and THEFT!
            I have repeatedly fired doctors over issues like these and have some good ones now.
            Neglect of my skin disease rotted my teeth. It also led to two hospitalizations of more than three days with cellulitis.
            The blood pressure industry provides doctors with something easy to measure and for which they have a reasonable chance of finding chemicals to alter
            Other illnesses require thought and work!

          • querywoman

            I really hope you are not still working in nursing with the attitude that a patient who wants an illness with symptoms treated is, “childish.”
            I leave medical offices with that kind of attitude.
            When I was younger, I often lacked the money to get promptly to another doctor.
            The correct way to address a doctor who refuses to address complaints, and that includes to not even discuss them, is to not pay the bill.
            I’ve not tried that much/
            I did tell a doctor once that, if he wasn’t going to believe me, I would just walk out the door.
            He said, “There’s the door.”
            I walked, and that was agreeable with me.
            He was a dermatologist. Just today, I went to my much better dermatologist at another medical center in town.

          • Teresa Brown

            Like I said, I wish you well in your search for doctors that satisfy your demands.

            I have nothing further to say to you, so I’m going to leave it at that.

  • John C. Key MD

    IMHO a covenant relationship is one between two parties. Thus, it is fairly easy to understand how the intervention of government, insurance companies, or other third parties throw a monkey wrench into the covenant relationship.

    Get rid of the third parties to restore the covenant.

  • Karen Ronk

    The first paragraph of this article is a beautiful description of what the doctor/patient relationship should be, maybe once was, and sadly, getting more rare these days.

  • querywoman

    Over 100 years ago, doctors got little respect. New treatments brought them real respect in the twentieth century, but they came with a cost, like antibiotic resistance. Then third party payers got too far into the business of healing.

  • querywoman

    Too often when I was sick, it was a nuisance. Meanwhile, the impotent docs hucked preventive medicine at me.

  • Peter Schwimer

    The social covenant or contract between business and labor has been broken in every other industry. Why not medicine? There was a time when industries believed that they had some responsibility to employees and the community. They provided living wages, benefits and support in return for honest labor. That is no longer the case. I am not going to go into why I think that is the case. It just is.

    Medicine, and indeed all of healthcare today is viewed as a business. Consequently, physicians who still see themselves as the top of the economic heap have suddenly discovered that they have to prove their worth, not to their patients, but rather to the business. Many do not like it. Many refuse to change their practice. They won’t make it in todays world.

    Many professions work dogged hours for much lower pay than the average physician. Nurses are on their feet 8-12 hours perday for significantly less compensation. As a social worker I understood going in that I would work long and hard under miserable conditions before I made any money at all. My choice, no one elses.

    I have had physicians working for me who were wonderful caring people. Worked hard. And others who did nothing but see the minimum number of patients and whined about it all day long. They whined about the hours, the schedule, the color of their office chairs.

    I do not know what the appropriate income for anyone is. We all think that we should make more. What I do know is that I made considerably more than any of my patients and that the physicians made more than that. I would not trade a day of my practice for anything. I would do it all over again and have just as much fun the second time as I did the first. If you aren’t having some fun at what you do, what exactly does that say about your choices? And why are you continuing to make the same ones?

    • querywoman

      Engineers and programmers work 100 hours per week, sometimes 7 days a week, without glamor and without overtime.
      They also lack a social activism mentality and lack power to change their situation.
      I live in a high tech area.
      Doctors and hospitals utilize their high tech playthings daily.

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