Our historic understanding of the doctor-patient relationship puts the individual doctor in charge of making all medical testing and treatment decisions when a patient seeks healthcare services from his/her healthcare business. The patient is expected to listen, answer the doctor’s questions, and follow all directions. Time is money and too much communication was considered unproductive.
This old doctor-patient relationship has not served the American patient nor the American taxpayer very well and has resulted in a very real “gap between high-quality, evidence-based care and actual care received by patients”. In one study that looked at fourteen acute and chronic conditions representing the leading causes of illness and death, Americans were found to receive proper diagnoses and recommended care ONLY 55% of the time! Recommended care is defined by established national guidelines and evidence-based clinical research data. Under the old doctor-patient relationship, many patients are subjected to wide practice variations with little to no real health benefit.
In another study reported in the Annals of Internal Medicine (see source below), Medicare spending variations from one region of the country to another (e.g., in 1996, $8414 per beneficiary in the Miami, Florida region compared with $3341 in the Minneapolis, Minnesota region) were largely associated with the QUANTITY of medical care provided. The differences in per beneficiary spending from one location to the next was NOT due to socioeconomic status, levels of illness, or even local prices of medical services, but to the fact that the doctors simply upped the volume of healthcare services they foisted upon the Medicare beneficiaries! In addition, the beneficiaries that received the larger QUANTITY of care did NOT receive a higher QUALITY of care nor an increased access to care. When there are more medical specialists and internists competing in an area (like Miami), the doctors increase the QUANTITY of unnecessary care to maintain a level of income. So much for the free-market healthcare system. The old doctor-patient relationship featuring a passive patient allows this practice to continue.
This old doctor-patient relationship delivers business-centered care and not patient-centered care. In other words, it is geared toward the financial needs of the doctor and not toward the delivery of best patient outcomes.
The “New” Doctor-Patient Relationship
The new doctor-patient relationship can be divided into two parts–one involving the interactions with a single healthcare practitioner and the other with more than one practitioner.
Patient-Engagement and Outside Clinical Data
When you seek medical attention you expect to obtain a diagnosis, appropriate tests to aid in diagnosis, and finally appropriate treatment for best patient outcomes. The new doctor-patient relationship is geared to provide the best patient outcomes and requires active patient-engagement. The passive patient is less likely to get the best or even the recommended care. Doctors will not willingly embrace a new doctor-patient relationship that takes some control of care out of their hands and will likely reduce their ability to maximize income through such practices as over-treatment and over-testing. Going from a business-centered model of care to a patient-centered model of care requires doctors to realign their thinking about the practice of medicine.
In addition to active patient-engagement, the new doctor-patient relationship demands that doctors (and patients) openly apply the best evidence-based clinical research data for testing and treatment decision-making. This evidence-based clinical research data can be used by both doctors and patients for best patient outcomes. Many research reports now include “Plain English Summary” sections so that patients are not excluded because of medical jargon (e.g., myocardial infarction = heart attack and adhesive capsulitis = frozen shoulder)
The figure below illustrates how the three contributions to the new doctor-patient relationship zeroes in on best patient outcomes.
Under this new doctor-patient relationship, the medical doctor draws on the knowledge obtained from his/her medical school education, his/her practical clinical experience, and data from evidence-based clinical research to present the patient with possible options. The clinical expertise of any given doctor must be continuously enlarged as new techniques replace old ones. In addition, the individual doctor’s clinical expertise alone is insufficient for delivery of best patient outcomes today.
The patient assesses the benefits and risks associated with each possible medical test and treatment and then makes the final decision. Patients need to be aware that the newest and costliest tests and treatments do not automatically provide the best patient outcomes. Patients also need to be aware that individual doctors might not be fully aware of benefits and risks associated with specific tests and treatments. Some doctors might even play up or downplay a given test or treatment to “guide” you down a particular (more financially advantageous?) treatment pathway. It is therefore in your best interest to either become more informed or enlist a patient advocate who can help you navigate treatment options.
Coordination of Care
The second part of the new doctor-patient relationship acknowledges the fact that the best patient outcomes are obtained when all healthcare professionals treating a patient at one time must consider the whole person’s needs, must communicate with each other, and must coordinate care. Care does not revolve around any given specialist, but rather around the patient. Under the new doctor-patient relationship situation, each specialist is no longer an island free to provide the care he/she thinks is best for a given body part. He must consult with the rest of the doctors treating the other body parts. For example, a cardiologist wishing to perform a cardiac catheterization needs to consult with a nephrologist if the patient has limited kidney function (the contrast dye used can cause kidney problems). Failure to coordinate the best medical interventions for the “total” person can result in much less than the best patient outcome.
It is no secret that under the old doctor-patient relationship environment, medical doctors incorporated as separate healthcare businesses do not communicate or coordinate care with medical doctors in other healthcare businesses, much less with healthcare professionals who are not medical doctors (psychologists, chiropractors, physical therapists, etc). While most patients consider their general practitioner/internist as their professional care coordinator, it is rare for a specialist (the kings in the medical community hierarchy) to treat them as such under the old doctor-patient relationship paradigm.
Summary—the “New” Doctor-Patient Relationship
The old doctor-patient relationship is about single healthcare businesses having total control of the healthcare they provide for the maximization of income. The new doctor-patient relationship is about patient-centered care that maximizes care for best patient outcomes. Because the new doctor-patient relationship threatens income, many long practicing doctors and doctors who haven’t practiced in a number of years (like our new Secretary of Health and Human Services, Dr. Tom Price) fight this new doctor-patient relationship.
The new doctor-patient relationship calls for active patient-engagement and the application of the best evidence-based clinical research data in care decision-making. Healthcare, often involving more than one healthcare professional, calls for communication and coordination between all involved in care and with the patient. The patient is not a passive set of body parts that can be carved up for treatment. What goes on in a single doctor-patient encounter is simply a small piece of the healthcare recipe for achieving best patient outcomes.
Fisher ES, et.al., The implications of regional variations in Medicare spending. Part 1: The content, quality, and accessibility of care, Annals of Internal Medicine, 2003a; 138(4):273–287.