Perhaps without realizing it, there has been a transition over the past decades in the way that Medicine is practiced that has resulted in less satisfied patients and more burnt out doctors. The jargon that we use to strictly describe these models of care include the terms paternalistic and patient-centered. In the paternalistic model, patients come for a visit and the doctor tells them what they need to do. In the patient-centered model, the doctor provides information with options and patients tell the doctor what they want to do. While both models certainly have their pros and cons, the shift and balance from placing responsibility on doctors for their patients’ health to putting responsibility on patients for their own health makes much more sense when put into the context of societal changes that have been marked by consumerism and liability.
As a doctor interested in the intricacies of the patient-doctor relationship, it’s interesting to think about how we share responsibility and decision-making. From there, we can start to explain why the doctor-patient dream team of the days of yore has fizzled into a relationship better represented by a grumpy old married couple. According to a report in the New England Journal of Medicine, 75% of people trusted medical professionals in the 1960s whereas that number has gone down to about 34% now. Additionally, only 56% were satisfied with their last doctor visit. Why did this happen? Having also been on the patient side of this relationship, I also yearn for a doctor I can trust. After all, we’re not talking about what we want for dinner; it’s our health at stake.
The first major reason I think the tables have turned is the concept of consumerism. It’s not that people don’t want to trust their doctor. It’s just that our culture has become accustomed to the idea that the “customer” is always right. We have the power of choice, the power to look things up, read reviews, and demand a top-notch experience. Whether it’s shopping on Amazon or going on vacation, the customer experience is everything. When it comes to a doctor visit, a good experience doesn’t always necessarily mean leaving happy and inspired. Inherent in the doctor-patient relationship is bad news. Almost everyone at some point will have to face the facts of abnormal blood work, a diagnosis, requiring a medication, needing a procedure, etc. While there are many empathic doctors out there that can break bad news like no other and truly do feel for their patients, wanting to help them, this idea that translates from other realms of society that the customer is always right may actually be harmful here. From the doctor’s side, the expectation is that of teamwork and a goal to accomplish what would be in the best interests of the patient. It takes many years of education and experience to become a doctor and research is constantly changing, which requires that people stay up to date on new guidelines and therapies. From the patient perspective, we all want a good doctor we can trust who knows us well and will help us accomplish our goal of living as healthy a life as possible.
Coming from the Hippocratic Oath, which doctors take in some form or another, “First, do no harm.” But what do we do second? Often times, as the bearer of bad news, doctors must in some way or another, inflict some form of harm on patients, which a means justified by the ends. It could be as mild as causing anxiety over awaiting results or as major as subjecting people to medications and procedures that might be risky. It’s important to remember that in order to accomplish benefits of improving quality of life or quantity of life – the main 2 reasons doctors do anything – the customer may not always leave happy from their doctor’s office. Nowadays, this is incongruent with consumer expectations we demand in other aspects of life. That said, the patient – a more appropriate and humanistic term for “customers” of the medical system – always comes first.
Related is the idea of liability has become infused into every aspect of medical care. Doctors often think about, or at least refer to, the “what ifs” to guide care of patients rather than what might actually be best. The medical community refers to this as “CYA,” or cover your ass, medicine. It’s almost impossible to avoid completely because the idea of missing something or making a mistake in diagnosis, however small the consequence, could result in unhappy patients. Unlike opening a package of broken goods, all sales are final in healthcare. Misdiagnosing something or even unintentionally causing harm can result in despair, shattered reputations, and getting sued. Inherent in the job of taking care of people is responsibility and risk, but the threat of punishment for “being human” has certainly resulted in a change of culture in the practice of Medicine.
To avoid accepting full responsibility on the side of doctors, patients have been granted more responsibility whether they like it or not. The analogy of this change in relationship dynamics I like to give is of someone shopping for a new computer. Assuming you have an average understanding of computers, if you needed a new one and were going to a store to get one, you would probably ask for help deciding what to get. The salesperson might ask you questions like, “What are you going to be using it for?” and “What are important things to consider for you in deciding on a new computer?” They wouldn’t read off all the technical specifications of each one and say, “So which one do you want?” That wouldn’t be helpful at all. So why as doctors should we feel the need to turn patient-centered care, a model that ideally represents shared decision-making based on a patient’s best interests, into patient-chosen care?
Going back to our analogy, the best salesperson would probably take your answers to more general questions, interpret them, and then explain the important technicalities to help you understand the reasoning behind a recommendation for you. Now take your health. You have a symptom. You go to the doctor… no, we all know that’s not how it works anymore. First, people Google their symptoms and find an overwhelming amount of information that may or may not apply to their situation. Then they ask their friends and family who share anecdotes of similar experiences and horror stories about how they might be dying. They find home remedies that don’t require a prescription, but are likely not evidence based and may actually cause harm. They may or may not work and then finally, people are convinced that they should ask their doctor so they make an appointment. When they tell their doctor about their symptoms, they don’t want to disappoint their doctor, so they don’t mention all the things they’ve tried that they read about. The doctor tells them what it probably is based on hearing the story and having gone through at least 7+ years of schooling and training – often more than that – after college to help answer your exact question. However, since people have access to exorbitant amounts of information that may or may not apply to them, patients start asking “what ifs.” Regardless of how low the chances are, it would be impossible to rule out certain things without certain testing. Likewise, when a doctor recommends a medication, it is often not something that came up in the Google search that came before the appointment. If it did, it was probably about a lawsuit related to an adverse event that happened, which was totally unrelated to the current situation. Alas, the information is there and enters as the elephant in the room.
It becomes easier to understand how competing interests, unspoken guilt, worry, and not wanting to disappoint on both sides hinders this therapeutic relationship. Unlike the computer store where people want an expert opinion about what they should do, the risk of causing a patient to leave unhappy or missing an extremely uncommon issue becomes front and center and dominates the undertones of the relationship.
How do we fix this? 2 things that must go both ways: trust and communication. Easier said than done, I know. If patients and their doctors can trust each other and communicate openly and honestly, we can begin to find a balance in models of care that allows patients to feel comfortable relying on the experience of their doctor and allows their doctor to openly share what they think.
If you have thoughts or questions about the patient-doctor relationship, models of care, or the practice of Medicine, ask here.