It’s time to revisit the 4 R’s of the doctor-patient relationship

“We have met the enemy in medical education, and he is us!”

My paraphrase of the “philosophy of Pogo” is pertinent to today’s crop of graduating medical students. We have inserted them into the most toxic environment for learning medicine, ever.

Dr. Michael Halberstam once stated that the most powerful treatment the ER had to offer (after CPR, of course) was “the sight of your own doctor at the bedside.”  Yet look at what our medical students are experiencing (and therefore learning) today:

A patient develops pain/illness during the day; by four o’clock in the afternoon, he is feeling worse and heads to the ER.  Here he meets a nice doctor (we’ll call him Dr. A) who takes a history, does an examination, and orders tests.  Before the results of those tests are returned, however, there’s a shift change. So Dr. A writes a six- to eight-page summary of the visit, including cutting and pasting all ordered tests, and leaves.

At seven o’clock that evening, Dr. B arrives for his ER shift; he introduces himself to the patient, takes a history, reviews the test results, and determines that the patient is seriously ill and needs admission to the hospital. Dr. B arranges that and then writes a six- to eight-page summary called the “ED discharge summary” (including cutting and pasting all tests) and moving on to another ER patient.

Our patient is admitted to the hospital, which is when  Dr. C, the evening-shift hospitalist (“nocturnalist”) arrives; he directs that the patient be admitted to a room “for observation.”  Unfortunately, there is no expectation of further diagnosis or explanation until the morning.

At seven o’clock the next morning, Dr. C writes the “transfer hospitalist summary” (a six- to eight-page summary of the previous night’s events including cutting and pasting of all tests), and signs the case off to Dr. D, the daytime hospitalist. Dr. C then leaves for his day-job.

Dr. D (the next Hospitalist to care for our patient) takes over and endeavors to further diagnose and/or treat the patient, usually by calling on consultants (Drs. E and F), who each write their own three- to five-page note.

When the proper treatment is initiated and the patient is improving, he will be discharged (after an eight- to twelve-page discharge summary is written) and given three- to five- pages of discharge instructions, including that he see his PCP within a day or two. The purpose of the visit to the PCP is for the patient to have his questions answered about what went on while he was hospitalized.

If the patient can see his PCP within two days, and if the paperwork has been sent to the PCP, the patient will finally begin to learn what’s going on with his health.  Unfortunately, most of that “post-discharge visit” will be consumed by the PCP digesting the thirty- to eighty-pages of data from the man’s ER visit and subsequent hospitalization.

This is the un-exaggerated truth about what I experience in my family medicine practice every day.  This is the environment our medical students are exposed to. How can we expect them to learn about the doctor-patient relationship this way?

A few years back, when I was caring for inpatients, a patient of mine was admitted to the hospital via the ER. Even with proper ER treatment, she later took a serious turn for the worse.  It was an unusual occurrence, so I went to the ER to speak with the doctor who had treated her.  He was doing paperwork and barely looked up as I told him what had happened.  He was so rude and dismissive that I asked if he cared to hear more.  “Not really,” he said.  I was incredulous.  “But how do you expect to learn from our patients?” I asked.

His reply was shocking. “I don’t care what happens after they’ve left the ER,” he said. “I give them the right treatment because it’s what the book says to do.  So what happens later is irrelevant to me.”

I hope this doctor never makes it onto a medical school faculty.

During residency training, I experienced an even more frightening event.  I was rotating through Obstetrics and arrived a few minutes early to relieve my fellow-resident.  He was in the delivery room, and the patient was crowning.  I reviewed the record and learned that she was a primigravida and had been in labor all night, under his constant care.

At 0800, I opened the delivery room door, and could see delivery was imminent.  I tapped him on the shoulder, saying, “I know you’ll want to finish up; just wanted you to know I’m here.”  As I turned to leave, he jumped up and left the room.  Naturally, I delivered the baby but was at such a loss for words I made no attempt to explain my colleague’s behavior. Actually, there was no explanation.

After many years of practice, I continue to try to teach medical students in my office the “Four R’s” of the doctor-patient relationship:

  • Responsibility: “It is I, and I alone, who have the responsibility for getting you well.”
  • Reliability: “I am reliable and you can count on me to fulfill my duty to you.”
  • Resources: “I have the resources to make you well, and if it is beyond my abilities, I have the resources to get you another doctor who will heal you.”
  • Reassurance: “I will effect Total Healing, which involves your confidence and hope that you will become well, and stay well.”

Hippocrates said, “Some patients recover their health simply through their contentment with the goodness of their physician.” Writing pages of words (mostly documenting why you should be paid the maximum fee), and providing treatment that is limited by the clock, does not satisfy my definition of “goodness of the physician.”

Gerald P. Corcoran is a family physician.

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