Practicing Medicine Requires a Patient Relationship

A reflection from 2013

Talking with an insurance doctor, who denied a vertebroplasty for my patient with a spontaneous compression fracture, I started thinking about the dilemma of defining what a doctor-patient relationship is.

A couple of years ago a local doctor with a dwindling private practice joined an Internet medical site that promoted drugs like Viagra and offered online consultations with physicians who prescribed the medications when they felt it was appropriate. The State Medical Board disciplined the doctor with a warning, a stiff fine and a permanent blemish on his record.

The charge was “prescribing without a physician-patient relationship”.

It struck me as ironic that providing a treatment long distance gets you in trouble with the Medical Board, but denying insurance payment for treatment of patients you have never met or communicated with is perfectly acceptable. It might even qualify you for a corporate bonus?

The managed care industry, on its own, redefined the doctor-patient relationship many years ago, and now the Internet and the Government are continuing the transformation.

In 1999, writing about the inherent conflict between being someone’s doctor and in reality also working for the insurance companies, Goold and Lipkin conceded that the doctor-patient relationship is still something very personal:

“The doctor–patient relationship has been and remains a keystone of care: the medium in which data are gathered, diagnoses and plans are made, compliance is accomplished, and healing, patient activation, and support are provided.”

Curiously, they then went on to create a breakdown of how doctors build trust during the medical interview, as if they might somehow be able to replicate it without the doctors’ involvement.

Today, of course, medicine has become less personal. Teams of doctors, PA’s, NP’s, nurses, medical assistants and health educators are engaging with patients during and in between visits. Patients are trying to get used to this kind of group health care, and are often expected to quickly open up and establish trust in these new “team members”.

Sometimes the teams are introduced as being physician-led, sometimes as being part of a trusted health care organization. The problem with some of the newly created entities, like Accountable Care Organizations, is that they are still completely unfamiliar to patients.

Many patients are worried that either too much or too little is shared between the members of the health care team: Too much and they feel their privacy threatened, too little and they worry their diagnosis or care will be incomplete.

In my opinion, each patient’s personal physician really needs to be the glue that holds together these new teams of health care workers. If physicians are not promoted as team leaders in this reorganization of patient care, patients will be tossed around in a haphazard fashion, where the care will be tangential – focused on what each team member needs to document for their own job security, but with no one to sit down and work through the hard decisions that inevitably arise when you are treating people, not numbers.

This role requires physician confidence and enthusiasm. It requires trust between doctors and their employers that they are working with the same vision. It requires a new view of the physician as more than a revenue producer; very soon we will not be bringing in more revenue simply by seeing more patients and charging correctly for our work.

Private practice physicians were once each at their own epicenter of a very fragmented, individualized health care system. The American insurance system reduced us to line workers in the big health care machine. Costs went up, quality went down, and now the Government is asking for Accountability.

The role of physicians is set to evolve again, from well paid widget makers to managers – of care, of staff, of resources.

Are we up for this new role? Do we also remember the ancient role of the physician? And can we bring it with us into the future?

The principles behind the physician’s role haven’t, or shouldn’t have, changed. Even the AMA, in its Code of Medical Ethics, speaks of the moral imperative in the doctor-patient relationship this way:

“The practice of medicine, and its embodiment in the clinical encounter between a patient and a physician, is fundamentally a moral activity that arises from the imperative to care for patients and to alleviate suffering.”

Accountability implies a moral or ethical foundation. If today’s doctors, working in today’s evolving health care system, are to retain the moral and ethical principles of our profession, the organizations they work within must adhere to similar principles. If the implied message is that health care wasn’t living up to the highest possible standards before, can an entire industry be made ethical?