Fixing the physician-patient relationship

I wish I had a dollar every time someone gets misty-eyed about the physician-patient relationship — and two dollars every time they say protecting it is the key to health care. That might be true, if you thought health care was awesome circa 1960.

Hereʼs what the physician-patient relationship meant back then: Physicians say, patients pay. We have seen little progress since then. The claim that the relationship is now symmetrical is simply false, and requires willful blindness to the deep imbalance in medicine.

Patients see this power disparity before we even see a physician. It starts as soon as you try to schedule an appointment: Are you new? First available in three months. Physicians donʼt call patients, begging them to come in.

And woe to the patient who is actively sick: You are totally at the physicianʼs mercy. That physician has your life in their hands: It’s not like they put a gun to your head, but it is a lot like somebody else put a gun to your head, and now wants your physician to decide whether to pull the trigger. And what damage that gun might do is secondary to the physicianʼs desire for payment. Everything about a visit to the physician reinforces a simple message: You need them, but they donʼt need you.

If the patient-physician relationship were at all balanced, you might expect physicians would embrace empowered patients. Not so: Witness the antipathy for the many online resources now available to patients, widely denigrated as “Dr. Google.” The knowledge a patient gets from a lifetime spent learning about and managing a disease is somehow trivial, compared to what a physician learns from a former cheerleader handing out pens. And if you disagree, youʼre welcome to roll the dice at another practice – three months from now.

The basic problem is that there are not enough physicians to satisfy demand. This is a direct consequence of physicians working to limit the number of physicians — that is, limiting competition to guarantee the lucky few command high salaries. In 1961, Milton Friedman called the American Medical Association “the strongest trade union in the U.S.” The lack of competition also means physicians have small incentive to behave better towards patients.

Moreover, the AMAʼs heyday is directly responsible for the state of medical care today. The expense — and lack — of care for elderly patients led to the creation of Medicare, widely reviled as enemy #1 to the physician-patient relationship. For all the supposed harm to that relationship, patients donʼt seem to mind: they are fervent in its defense at the polls.

Worse, the easy money of the medical monopoly lured players even more ruthless than the AMA. Pharma companies, corporate hospitals, and private insurers all grabbed a chunk. Even medical schools  took a piece: Tuition rates are driven by what graduates are expected to earn. The whole greedy mess is a feedback loop, driving the heavy price of health care, all on the backs of patients.

Physicians are upset to find themselves next lowest on the totem pole. They donʼt earn as much money as they want, and their jobs arenʼt as easier as they like, but letʼs be clear: They still want a place on the pole. Their desire to saw off everyone above them just means they want to be the only ones standing on their patientsʼ backs.

The irony is that many physicians claim patients are too dumb or lazy to value the physician-patient relationship in health care. Itʼs more accurate to say that many patients have been conditioned into apathy by exactly that relationship. Empowered patients know better than to trust in physiciansʼ empty nostalgia.

If physicians really want to fix health care, they can start by fixing their relationship to patients. That means correcting the power imbalance: Accepting patients as equal partners, giving them control over their treatment, and being sensitive to the extreme financial and social burden medical care puts on them. Physicians should begin with self-reflection, to appreciate how their own professional customs and attitudes reproduce the toxic dynamic corroding our health care system.

Patients cannot be allies to physicians, so long as we are their subjects. Patients need to be empowered to advocate for their interests in the health care system. When empowered patients see a relationship worth protecting, we will work to protect it.

So, yes: I wish I had a dollar every time someone mentions the physician-patient relationship. But more than that, I wish I could believe it.

Duncan Cross blogs from the perspective of a patient at his self-titled site, Duncan Cross.

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  • Eric Strong

    Doctors and patients should be equal partners in their care, but that does not mean they have equal knowledge.

    Doctors need to understand that medical school and residency may make them an expert in disease X, but that training does not make them an expert in how disease X is affecting the patient in front of them.

    And patients need to understand that first hand experience with disease X may make them the only expert in how it affects them, but that does not make them more knowledgeable of the disease in general than the doctor in front of them.

    • Patient Kit

      Agreed. Doctors have far more knowledge and experience in medicine, in general. And we patients know far more about ourselves, our bodies, our lives and our priorities. We each bring different areas of expertise to the table in a good doctor/patient relationship. Good communication is key for this partnership to work. And, of course, we are all equals as human beings and should treat each other accordingly.

    • Duncan Cross

      Sorry I’m just now getting to this — vacation — but I tend to agree. The problem is that, in my experience, physicians almost always value their knowledge over the patient’s.

      • PoliticallyIncorrectMD

        Really! This is a problem? Last time I checked, you came to see a physician for their expertise. I doubt they came to your home and forced their opinion on you.

        • Duncan Cross

          I should have been clearer: physicians almost always value their knowledge to the exclusion of the patient’s.

  • southerndoc1

    “correcting the power imbalance: Accepting patients as equal partners”

    I have no interest in being an “equal partner” with my lawyer, accountant, dentist, or car mechanic. I am paying them for their knowledge and skills; if anyone of them wants to treat me as an equal in their area of expertise, it’s clear I’m dealing with an incompetent shyster and I high-tail it out of there.

    • JR DNR

      I went to car mechanic A because I knew I was behind on car maintenance and needed an oil change. He gave me a long list of items I couldn’t afford. I chose the highest priority items.

      Next time it was more convenient to go to a different mechanic. It turns out mechanic A gave me a bunch of items that aren’t part of the recommended schedule maintenance for my car at it’s current mileage or age. Car mechanic B showed me in my car manual where the recommendations were and they are now up to date. B also did a car inspection for any potential problems and didn’t find any. I don’t need to do all that additional work.

    • Duncan Cross

      Well, I think medicine is more significant to sick people than your car mechanic is to you. It’s not apples to apples.

    • mick

      I don’t want equal partneship either. I want an unequal partnership where my needs, desires, and wishes trump those of my doctors just as I have with any car mechanic, plumber, or lawn care person I hire. It’s my money. Whatever gets done it should be done to satisfy my needs, not someone else’s, and should only be done with my approval.

      When you get your car repaired, do you say, “just do whatever you want”, or does he call after diagnosing the problem, explain the alternatives, and let you make the decision? I know most people would be pretty ticked off if a mechanic just jumped in and made repairs without discussing alternatives and asking for permission to do the work.

  • querywoman

    My favorite term for preventive medicine: “when sick people can’t get medical care.”

  • SteveCaley

    Here are some simple ideas:
    -> Deregulate non-addictive medications. (non-DEA drugs.)
    -> Lift any “mandates” on giving medical advice. Recommending non-prescription drugs (such as lisinopril) for conditions (such as hypertension) should not be a matter of legal concern.
    In short – go to full American Retail Medicine. We do it at Target, and Wal-Mart; and you can buy dangerous and lethal things at Wal-Mart, such as lawnmowers and guns. Why not glyburide?
    Anyone who WANTS a doctor can HAVE a doctor. Why should someone who doesn’t WANT a doctor then have to PAY for a doctor?
    This is what is coming – whether we like it or not. By 2020, it is the New Healthcare.

    • PoliticallyIncorrectMD

      Are you promoting population control?

      • SteveCaley

        Societies decide whether they are sane or insane. We may be observing population control; it hardly needs promotion. It is already the civil delusion.

    • Duncan Cross

      You might appreciate one of my previous posts on this site: Real Market Reforms for Health Care — http://www.kevinmd.com/blog/2014/01/real-market-reforms-health-care.html

  • SteveCaley

    As above – lift the mandate and let the market decide!

  • PoliticallyIncorrectMD

    Perhaps we should level the playing field even further and let so called “empowered” patients be responsible for their own health care decision. Want to be equal partners with your physician? Great! How about bearing equal responsibility if something goes wrong?

    • Margaret Fleming

      A family member now dead, and now one close family friend who may not live are victims of bad diagnoses from the same famous medical group. We need to be more than in charge with that kind of caregiver.

      • PoliticallyIncorrectMD

        Completely agree… I would defenitely find another group… But there is a difference between having control over choosing your physician and telling them how to practice medicine.

        • rbthe4th2

          If some of them knew how to practice, we’d be fine. State boards and the like are all too set up to let physicians do whatever until things are way out of hand and horrible. Some of them really do need to relearn how to practice or shouldn’t have been allowed in the first place, but there is so much emphasis on how much $$$ they paid for med school etc. rather than patient safety and health.

          • PoliticallyIncorrectMD

            So what consumers do – take your business elsewhere !

          • rbthe4th2

            Why is the mindset that patients should just blow off and go elsewhere (maybe they have no place to go) and NOT that the doctors reform their ways and follow the original intent which is to serve their patients and not allow biases or who you know/like to get appropriate care? Why is that acceptable? Should it be acceptable that the poor get shoddy care? Should it be acceptable that minorities be treated less equally?

          • PoliticallyIncorrectMD

            I am not defending bad doctors or substandard care. I am just pointing out that while those realities unfortunatelly exist patients still have a choice. But going to bad doctor and demanding them to change is absurd. Just find the good one and let the other one go out of business.

          • Duncan Cross

            PIMD — the larger problem is that there aren’t enough physicians for there to be real competition among the good and bad. This is a big part of the article.

          • PoliticallyIncorrectMD

            Interesting ! In 2010 there were 850,000 actively practicing physicians in the US. Number of physicians per capita in the US is compatible or exceeds that in most european countries. Yet, there is not enough physicians for you to find a good one. Not only it is statistically impossible, but also it tells me a lot about your agenda. You either have no clue about what physicians do and have unreasonably high expectations of them. Or you suffer from paranoia and think that physicians are out there to get you. Or you want to find somebody to blame for being unfortunate to suffer from your medical condition. Which one is it? Anyway, I find it ironic that you chose physician forum for physician bashing.

          • Duncan Cross

            I have found good physicians, but it took more work than it should. Lots of patients don’t have the time, money, or energy to comparison shop to the extent that I do — and most of those 850,000 are specialists. I see no evidence that competition alone puts bad physicians out of business.

            My agenda is this: if we want to talk about the patient-physician relationship in health care, we need to be clear on what that relationship looks like from the patient side. I chose this forum exactly because physicians need to see that other side.

          • PoliticallyIncorrectMD

            “I see no evidence that competition alone puts bad physicians out of business.” So what is your solution- demand that they change? I am afraid you’ll be looking for another physician anyway.

          • Duncan Cross

            Well, my stopgap obviously is that we not talk about the physician-patient relationship like it’s an awesome baby unicorn. Longer term, we need more physicians and better accountability.

        • mick

          Its not about patients telling doctors how to practice medicine. Its about doctors and patients discussing whatever the situation is so that both sides know the risks and benefits, and so that all the bases have been covered, then making a joint decision. what is so often missing is the doctor listening to the patient so that he/she knows what the issue is, and the doctor explaining all possible courses of action so that the patient can make a choice based on his/her own values. What happens more times than not is the doctor does not explain the risks of a particular course of action, then the patient is stuck with the results when things go wrong because he was not even aware of the risks. The concept that “your doctor will decide for you” (as is so commonly stated in ads for drugs, and treatments) is just plain wrong. I don’t want my doctor deciding anything for me. His job is to inform me so that I can make the decision being fully aware of all the plusses and minuses.

          • PoliticallyIncorrectMD

            I agree with you, the final decision should always be up to the patient… What I don’t get is how can anybody force you to do anything you don’t want doing. If you disagree with your doctor or not happy with their explanation, what forces you to stay? Why not take your business elsewhere?

          • Duncan Cross

            Thanks, Mick — this is exactly how I would have responded.

    • rbthe4th2

      I would be if the physician who controls the final decisions would go with that. They don’t. There is where the rub is. The biggest issue is when they are wrong and I am right, they don’t want to take responsibility for being the decider. The ones who’ve been a partner, they are the ones that have been up being right.

    • mick

      I’m all for that. If, however, a doctor forces a patient into a particular treatment because he doesn’t listen to the patient, then it should be all on the doctor if something goes wrong – fair enough? This is by far the more common source of things going wrong in my experience.

      • rbthe4th2

        I agree with this. This is what happened to me.

    • Duncan Cross

      Deal! Equal responsibility would be great — a step up. So far I have born all the responsibility for the mistakes physicians have made in my care. I don’t mind being wholly responsible for my illness; I’m only asking that my physicians recognize that responsibility.

      • PoliticallyIncorrectMD

        I think you are confusing responsibility for mistakes / treatment decisions with having control over “getting” your disease or its unfavorable course. Blaming physicians for the latter may help you to feel better emmotionally, but it is completely irrational and inappropriate.

        • Duncan Cross

          No, no confusion. I know what’s mine to bear and what’s not. This isn’t about blame or control, it’s about what a real partnership looks like between a patient and a physician. It’s a rare beast.

  • Margaret Fleming

    When I blog about Who’s The Boss of Your Medical Care, I get my biggest readership. And it took me a year or more to get physical therapy in my new state. I’ve had some spectacular medical care from some amazingly caring doctors. But when it’s bad, it’s bad.

    • Duncan Cross

      I’ve had some great docs, too, and I have a physician who comes pretty close to my ideal of ‘partnership’. But I have also had some jerks, and a couple who nearly killed me.

      • PoliticallyIncorrectMD

        Ever considered the fact that it is your disease that nearly killed you, not the physicians.

        • Duncan Cross

          Yep. Every day.

  • rbthe4th2

    Yes!! I agree on this one. 100% true – thank you Duncan.

    • Duncan Cross

      Thanks.

  • logicaldoc

    All sounds hunky dory; except the reality of all the other dynamics the Physician is facing, particularly all the other “third-party” entities that truly define the Patient-Physician relationship (Lawyers-Defensive Medicine, Administrators-financial outcome measure monitoring, Insurance companies-who define what you will be able to receive ultimately, etc.) needs to be truly understood for any “real” insight into this problem. But hey; it’s always the Doctor’s fault. That is the Society we live in: classic “transference” of blame to the person on the front lines, when the problems are much deeper than that. This occurs in Teaching, in Politics, etc. Our ignorant Society always wants to put band aides on the “Symptoms” of a “problem” instead of concentrating its efforts on the illness. May I suggest sending your article to all Lawyers (if you think that there isn’t a massive ubiquitous conscious and subconscious Practice of Defensive Medicine that exists out there purely out of the fear of unregulated greedy Lawyers manipulating the negative outcome Market regardless of merit, you need to read my first book), Hospital Administrators, and Insurance Company CEO’s and ask them to get out of the way of your relationship with your Doctor?

    • Duncan Cross

      I’m perfectly aware of the problem of third-parties in medicine, but I also know how they got there in the first place. I think the instinct to blame lawyers is exactly the opposite of the introspection I asked for in the article. Physician: heal thyself!

      • logicaldoc

        Thank you for your response. However, as I implied, you cannot heal a necrotic wound without debriding it first. It is quite naive to think the dynamic of the Patient-Physician relationship can change anymore without getting to the core problems. You also imply in your response that we Physicians aren’t already attempting to have Patients involved in their care as much as possible. Well this Physician has long been ahead of the curve and that is how one realizes the road blocks that have been put up that get in the way. I prefer to continue my best attempts to involve Patients, but intellectually would rather not ignore or be ignorant of the true problems out there. This is where efforts to educate should be and this is what I do. Once again, redressing the necrotic wound with a brand new bright white bandage does not rid of the underlying necrosis that exists.

        • Duncan Cross

          I can believe — and be grateful — that you are doing all you can to have patients involved in their care. But that is not true of many, maybe most of your colleagues — and that is often not what most people have in mind when they talk about the physician-patient relationship. I think to solve the problems you talk about, we need to start from a firm footing: a meaningful physician-patient relationship. That relationship has to empower patients to be their own best advocates, or else those problems will never be solved in a way that reflects patients’ needs.

          • logicaldoc

            I can only speak for myself. Your opinion of my colleagues I don’t necessarily disagree with in general; but I would likely disagree with the degree you emphasize. I also believe that a firm footing of establishing a “meaningful” physician-patient relationship is key to the relationship; but I would go further and claim it to be an “axiom” of the relationship. Perhaps this is the reason I am giving you the perception that what you say is “secondary”. Without the “axiom” of meaningfulness in the physician-patient relationship, it should not exist. This is basic for me (a Board-Certified Physician for 23 years). So my springboard begins beyond this. That is why I now concentrate my Mind on what’s keeping this from evolving better than it can currently be maximized at. This means actually doing something about those “third parties” now; instead of only speaking about them and blaming everything on Physicians.

  • Ed

    What power imbalance? Patients have the ethical and legal right to choose who participates in their healthcare (physician, PA, NP, nurse, tech, assistant, chaperon, scribe, or shadow) as well as deciding what treatment, procedure, or medication their subject too.

    • Duncan Cross

      Yeah… not as much as you might hope. Physicians can and do bully their patients into treatment or medications, and it’s actually harder than you’d guess to pick who participates in your treatment.

      • Ed

        Well aware of the bullying aspect because I’ve been on the receiving end but a straightforward “what part of no, the n or the o don’t you understand” has worked every time. And it’s generally not the physicians that are guilty but their ancillary staff; if they only knew!

        • Duncan Cross

          I tried something similar once, and was more or less held prisoner in a hospital, threatened with AMA (Against Medical Advice). I’ve also had doctors refuse to write for me unless I took a drug I didn’t want. I don’t think it’s as easy to stop as we might hope.

    • PoliticallyIncorrectMD

      Exactly! This whole article is about blame and control issues, which are unfortunately common in patients with chronic debilitating diseases.

  • Duncan Cross

    Economically speaking, too much demand and not enough physicians are the same problem. I don’t enough about the lives of well people to say whether they are spending too much time with their physicians.

  • Duncan Cross

    Tend to agree, and I think physicians could be strong allies in helping patients take control of their care. But too often, they aren’t.

  • Duncan Cross

    We’re just beginning to explore what it means to be an empowered patient; in the 20 years I’ve been sick, I think I have already seen positive change. I am confident there will be more and better.

  • PoliticallyIncorrectMD

    I am not a big fun of comparing healthcare with airline industry, but just could not resist the temptation this time. How many of you would dare to enter the flight deck at 30,000 ft and “collaborate” with pilot on how to fly 747? But doing it with your physician is somehow appropriate!

    • Ed

      As an airline pilot, I do understand the analogy, especially with three burning and one turning (ER scenario to you), but the 747 is an inanimate object vice my one and only pink body. So, yes it’s entirely appropriate.

      • PoliticallyIncorrectMD

        While the plain is inanimate object, as pilot you are responsible for lives of those on the plain. You are telling me that during crisis situation on the flight (which is somewhat analogus to my every day in the intensive care unit) you’ll be asking your passengers’ opinions on how they want you to handle it. Really?!

        • Ed

          I was agreeing with your collaboration analogy specifically in crisis scenarios only. My comment applies only to those non-crisis interactions between physicians and patients, the vast majority of patient experiences. The point, despite our endearing nicknames for the 747, is “she” has no thoughts or feelings about how we treat her unlike your interactions with patients. Clear as mud?

  • logicaldoc

    “Showing up at your office does not give you power of attorney over me.” Mick; I agree with your sentiments (in general) and I am unaware of myself or my Colleagues ever doing such things as you mention. But based on this thread, it appears some people either have not taken the responsibility themselves to find a Physician that works well for them, or there appears to be a lot of “Transference” of anger onto Physicians. As usual, however, once again the focus is always to blame the “Front Line” people (Physicians) without truly understanding the dynamics of all the forces behind the scenes that dictate Healthcare to the Pawns involved (both Patients and Physicians). No one appears to want to dig further for the real truth because it’s so easy just to “Transfer” frustration, anger, etc. onto the Physician.

    • logicaldoc

      “Would you like it if you hired me to cut your grass and I just cut it however I wanted? If you say you want it cut long, and I cut it short because I arbitrarily think it is better that way, would you like that? Would you feel like you got your money’s worth? What if I cut it short and a sprinkler head in your lawn get damaged as a result because we did not discuss that, or because you thought any one with half a mind would check for high sprinkler heads, and I thought anyone with half a mind would not having sprinkler heads sticking up that far? You’d be fired; plain and simple. I would hire someone else.

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