Open up. Doctors need more transparency.


“Transparency” is the name of the game in the 21st century. Transparency is now required in any service-oriented profession, whether plumbing, law or real estate. Now, transparency has made its way into the field of medicine. I say this because medicine has historically been an opaque profession. Many physicians leveraged the fact that they were put on a pedestal to deliver a paternalistic style of medical care.

With the advent of commercial medical insurance, the presence of a third party clouded the glass of the patient-doctor relationship exponentially. Patients paid co-pays to see the doctor who was unsure of when and how much of their charges would be reimbursed. Billing agencies were hired to help, but more ancillary staff requires more supervision — enter practice managers. With increasing overhead costs and dwindling insurance reimbursements, physicians ramped up their volume of patients to compensate. Visit time subsequently decreased, leaving less time for full disclosure of medical conditions to the patient. Patient concerns are put off to nurses and medical assistant instead of handled by the physician due to time constraints leading to clinic inefficiency and increased medical errors.

But not anymore. The medical profession cannot afford to the ignore the need for transparency in practice. Patients are curious about their health, and access to health information abounds. Direct-to-consumer advertisements frequently surround programs with high viewership. Patients proactively bring their concerns about their medications or conditions into the office. Printed research articles in tow, they expect to have a thorough face-to-face discussion about their concerns with their physician.

We ask our patients to be as transparent as possible with us, how much more should we be with our patients? If we are willing to put down our own facades of being holier, healthier or smarter, we might become more of a person to the patient, one they might actually confide in, versus an authoritarian figure holding them to unachievable goals.

I remember the first time I resolved to get in better shape after college. I was a third-year medical student about to begin my clinical rotations at Parkland Hospital. I was motivated by the desire to be a credible witness on the effects of a healthy lifestyle. I exercised, slept well, ate right and felt great! My first challenge to maintaining those gains came during residency. 80-hour work weeks, high-stress situations in the ICU, ER and labor and delivery units and unlimited snacks and sodas while on-call became my excuses for loosening my grip on those healthy habits. I told myself I was in “survival mode,” and “as soon as this rotation is over, it is back to the gym for me!” Despite coauthoring an article on the effects of exercise and diet during that time, my grip on my health continued to loosen.

Around that time, I heard about this concept of four windows. One window represented what I knew about myself but only revealed to my family and close friends. The second window represented the favorable aspects of myself I consciously projected to other people. The third window represented the aspects of my life that were truly transparent for all the world to see and the last window represented the part of me that I knew but kept from others. The concept was that we need to make the largest window the fully transparent one, because it is too time-consuming and difficult to look through the others.

I never thought of myself as guarded until then. I suspect it developed as a defense mechanism during childhood and was mastered in medical school. We were asked as students to take care of the most vulnerable population in the city. We had to learn to put on a strong face to convince patients to get the care they so desperately needed but knew little about. We learned to “toughen up” so we wouldn’t break down when giving a poor prognosis. While you do have to be tough in training, to be able to separate emotions from clinical facts and to deliver them clearly and succinctly, it is a skill to be used and not a persona to assume. Once I realized that, my practice style changed. It took some time, but I learned how to be more authentic and open, sharing anecdotes from my own life to relate, encourage and teach, which improved the fulfillment I felt at the end of each day. When I was doing well health-wise, I would share how I was doing. When I wasn’t, I shared that too, to show I recognized the challenges of reaching and maintaining healthy goals. My patients know my childhood nickname was “Cookie Monster” and congratulated me with high-fives when I made it to the front row of Zumba class. I sympathized with them when they suffered a sidelining injury and empathized with the feeling of deep frustration after missing out on that coveted gym class. Transparency in health care is not the same as oversharing. It is allowing yourself to come through in a way that augments the care of your patient.

As medical billing works to become more transparent, more primary care physicians are considering changing their practices to a direct model of care to remove the middle-man completely. HIPAA laws are being revised and revisited in health care systems around the country to protect the private information of our patients. Informed consent is required before any major procedures to make sure patients understand the benefits and risks they are being asked to take. While these measures address transparency on a large scale, by showing humility, respect for the other party and acknowledgment of the risks involved in treatment recommendations, transparent physicians will do far more to advance the quality of medicine in America.

Stephanie Cudjoe is a family physician.

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