The Importance of the Doctor-Patient Relationship, and Why We Can’t Have It Anymore

Posted on January 23, 2009
Filed Under An Introduction to Covert Rationing |

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1) Why The Doctor-Patient Relationship Is Still Important

Regular readers will know that DrRich has a high regard for the classic doctor-patient relationship, and greatly mourns its loss. Of course, DrRich will be the first to admit that even in the good old days - when he was a young physician, for instance - this relationship was never actually perfect. But until a couple of decades ago, at least it was pretty well understood what the doctor-patient relationship was for. Today, DrRich laments, that is no longer the case.

DrRich is one of those anachronists who believes that a strong, traditional doctor-patient relationship is vital to the physical health of the patient, and the professional health of the physician. But not only is this view not generally held today, it also has been actively disparaged by insurers, regulators, healthcare policymakers and thought leaders, the US Supreme Court, and even the physicians’ own compromised professional organizations.  This, DrRich feels quite certain, is too bad.

To illustrate why the doctor-patient relationship is actually still important, DrRich will resort to an analogy:

One-day, down on your luck and in need of some quick cash, you decide to rob a Seven-Eleven. You rush in brandishing a .22, and order the clerk to hand over all the cash. Instead of jumping to the task the clerk stalls and gives you a hard time; you panic and shoot him. You quickly clean out the cash register and head for the door - where you run smack into two burly police officers who happen to be entering the store right then for some of that good Seven-Eleven coffee. You are quickly and none-too-gently disarmed and arrested.

So there you are - caught red-handed, money in one hand, gun in the other, the blood of the clerk on your shirt, and for good measure the whole episode has been recorded, in living color, by a hidden video camera.

Now, here’s the question: What rights are you entitled to?

It turns out, despite the fact that anybody can see how guilty you are, that you have many rights.  You have the right to a fair trial.  You have the right to be considered innocent until a jury of your peers declares you guilty.  And you have the right to appeal the verdict (assuming, of course, that you won’t like it).

But most importantly and above all else, you have the right to counsel, an advocate, an individual who is obligated to defend you against all odds, to the best of his or her abilities, and to protect your interests against the world.

Many physicians find themselves envious of the unbending resolve with which lawyers are able to embrace their most basic role of advocate.  Lawyers retain this luxury because society recognizes the legal system to be a morass of rules and regulations which ordinary citizens cannot hope to navigate on their own.  Any citizen who becomes embroiled in this morass is universally acknowledged to have the right to a lawyer who is expected to hold that citizen’s interests above all others (within, of course, the constraints of the law).  Even those accused of the most heinous of crimes are entitled to legal representation, and even if the evidence against them seems overwhelming, their lawyers are expected to jealously guard their rights.  While the rest of us may become frustrated and angry when we observe the rights that accrue to (in our eyes) an obviously guilty party, on an objective level most of us understand the wisdom of such a system.  And we shudder to think of the abuses that would occur if these protections were removed.

When you are sick, shouldn’t you be entitled to the same protections as when you are caught committing a crime of violence?

Most of us think so (except, apparently, for those insurers, regulators, healthcare policymakers, etc.). And that’s exactly what the doctor-patient relationship is supposed to do.

Sick people are no more capable of navigating a complex and hostile healthcare system than are accused felons a complex and hostile legal system, and are no less in peril if they run afoul of that system.  And a patient’s need of an advocate, a professional whose job it is to protect his or her individual interests against the conflicting aims of the “system,” is no less vital than that of the felon. When you are sick, you should be entitled to at least the same protections as when you rob a Seven-Eleven.  And the doctor-patient relationship is supposed to see that you are.

Over the ages the doctor-patient relationship has been defined, through rules of ethics and rules of law, as a fiduciary one, as a relationship founded in trust. When a patient seeks a physician’s help and the physician agrees to give that help, a special covenant is made.  The patient agrees to take the physician into her confidence, to reveal to him even the most secret and intimate information related to her health.  The physician, in turn, agrees to honor that trust, and to become the patient’s advocate in all matters related to her health, placing her interests above all others - including his own personal or financial concerns.

Now, to be sure, the doctor-patient relationship was never close to pristine in actual practice, but a strong fiduciary relationship has been what patients have expected, what most doctors have striven for, and what everyone else has traditionally agreed - and even demanded - should be the standard.  It represents the fundamental expectation of how doctors and patients are supposed to behave toward one another.

The loss of this doctor-patient relationship has obvious consequences for patients.  Patients, when they are sick and thus least able to fend for themselves, are left without a true, dedicated advocate as they try to navigate the hostile halls of the healthcare system, whose chief concern is to find ways of not spending money on them. Loss of the traditional doctor-patient compact leaves patients marginalized and floundering within that system at the time they are most vulnerable.

Less obvious, but no less profound, are the consequences of a destroyed doctor-patient relationship to the profession of medicine.  Abandoning their primary obligation to the individual patient means that physicians have committed the “original sin.” They have abdicated their traditional, ethical, and legal roles as patient advocates; they have broken a sacred pact. They have fully compromised themselves as professionals; indeed they have become professionals in name only, and not in fact.  And as a result, to their utter frustration, they find themselves standing naked before their enemies, the very insurers and regulators who forced them to abdicate their sacred obligation in the first place.

Thus, the traditional doctor-patient relationship is vital to the professional survival of the physician, and to the physical survival of the patient.  If we lose this relationship, we lose everything.

2) Why We Can’t Have It Anymore

A deadly wedge is being driven today between patients and their doctors, destroying the sanctity of their time-honored relationship, leaving each to fend for themselves in an increasingly hostile healthcare environment, and placing each at the mercy of powerful interests whose only real concerns are costs, profit and power.  As a result, both doctors and patients are being shunted aside, separated from one another, marginalized, and reduced to mere ciphers.

But why? Well, as DrRich has pointed out many times, the destruction of the doctor-patient relationship is central to covert healthcare rationing.

Simply put yourself in the place of an HMO executive (or a Medicare administrator, or one of the other individuals we have deputized to reduce our healthcare costs).  When such a person looks out over the landscape of medicine as it was traditionally practiced, he beholds a frightening scene: over two million times each day, individual physicians and individual patients - just the two of them, alone in a room - make millions of individual decisions about which healthcare resources should be called upon for the sake of that individual patient, at that particular time.  And when each of these decisions is finally reached, and the doctor places pen to paper and signs her name, the entire medical-industrial complex immediately bends to her will.

And our executive and our regulator break out into a cold sweat, and mutter, “They’re spending my money.”

Actually, they’re spending society’s money.  But whoever has dibs on the money, the fact remains that we can no longer allow such spending decisions to be made in a vacuum, as if the cumulative effect of those individual decisions on society are irrelevant. Since we cannot affect those individual spending decisions through an open system of rules - since that would be rationing, and Americans don’t ration - we must affect them in some other way.

To both the HMO executive and the government regulator, the answer is quite simple.  Coercive pressure must be applied at the focal point of all healthcare spending - the physician-patient encounter - to force spending decisions to be made on the basis of something other than what is best for the patient.

Covert rationing requires that decisions made at the bedside be made with society’s priorities in mind, and not the patient’s.  Covert rationing demands that the doctor forego his primary duty to his patient, in favor of “the greater good.” The demand is non-negotiable - and there is no need to negotiate with doctors, since the insurers and the regulators have succeeded in gaining full control over the individual physician’s professional viability.  If doctors are reluctant to give up their traditional role as their patients’ advocates, they must be coerced into doing so, and the ones who still refuse need to be weeded out. The engine that drives covert rationing must be - can only be - the systematic destruction of the traditional doctor-patient relationship.

So our abandonment of patients to their own devices in a hostile environment, in their very hour of need, and at the very time they are least capable of fending for themselves, has been purposeful and ruthless.  The systematic devaluation of the medical profession to the point of worthlessness has been equally focused and deadly.

This all seems pretty serious to DrRich, who still identifies quite a bit with physicians (having practiced as one for decades), but who now most especially sympathizes with patients, since that is destined to be his remaining role within the healthcare system.

Covert rationing - whether it is conducted under our current system, or under some new reformed system which will also fail to openly acknowledge the need to ration - demands that the doctor-patient relationship remains destroyed.  So, while the doctor-patient relationship will undoubtedly be awarded a huge amount of lip service as we contemplate healthcare reform, it can never be allowed to actually flourish again.

While covert rationing  (instead of open rationing, our only other choice) remains the driving force behind American healthcare, doctors and patients who want to form a traditional, fiduciary, and mutually beneficial relationship, are going to have to find ways of doing so that are not sanctioned by the official healthcare system.

And DrRich remains very sorry that this is the case.

Comments

8 Responses to “The Importance of the Doctor-Patient Relationship, and Why We Can’t Have It Anymore”

  1. NG on January 24th, 2009 10:09 am

    Dr. Rich,

    I understand that pooled payment mechanisms may not pay for certain processes, and that fact may lead to anger if patients knew that the forbidden process (from a payment point of view) was considered a good process by some providers, especially their provider. However, you make a large case that providers are cooperating in a covert scheme to deny patients the providers’ real opinion on such forbidden processes. My question, which is at the core of your covert argument here from a provider point of view, is what makes providers not tell patients what they believe in truth whether it is covered by pooled payments or not?

  2. DrRich on January 24th, 2009 11:20 am

    NG,

    Controlling the behavior of docs (specifically, PCPs - they generally can only “control” specialists by trying to limit referrals from PCPs) is a major thrust of third party payers, both insurers and the government, and it has been a major theme in my blog and in my book.

    I’ll simply refer you, for now, to the category (middle column of the blog) on Primary Care in America for a few of these posts. I will be putting up another relevant post this coming week.

    You might also read about Gag Clauses (http://covertrationingblog.com/gekkonian-rationing/why-gag-clauses-are-obsolete), and the portions on my GUTHealthcare website on how managed care companies (http://guthealthcare.com/understanding_it/modern_managed_care.html) and the feds (http://guthealthcare.com/understanding_it/feds_regulatory_abuse.html) control physician behavior.

    Rich

  3. Dr. Val on January 26th, 2009 8:15 pm

    Have you read George Lundberg’s book, “Severed Trust?” As his book’s title suggests, he comes to a similar conclusion about the underlying problem with healthcare.

  4. DrRich on January 28th, 2009 8:57 am

    Val,

    That book is on my list, but I haven’t gotten to it yet.

    Rich

  5. james gaulte on January 28th, 2009 3:17 pm

    While I continue to believe your analysis is correct, I wonder if there is any place in the world where in the medico-economic system “allows” the physician-patient relationship to exist as it more or less did in the past.Do systems of overt rationing (I’m thinking of Canada)provide an environment for the kind of physician-patient relationship that we mourn?

  6. DrRich on January 30th, 2009 2:03 pm

    Dr. Gaulte,

    Not in the way you and I think of the doctor-patient relationship. In most and possibly all countries I know of that have nationalized systems for healthcare, doctors don’t tell the patients everything - they only tell them about the centrally prescribed options. One can argue (and the ones I have talked to do) that this is only humane. And perhaps it is, in systems where the patients’ prerogatives to go outside the system, to use their own resources for their own benefit, are severely limited by law or otherwise. In a completely paternalistic system (which such systems invariably are), paternalism must prevail.

    Rich

  7. Anon on February 17th, 2009 10:04 pm

    “the need to ration - demands that the doctor-patient relationship remains destroyed. So, while the doctor-patient relationship will undoubtedly be awarded a huge amount of lip service as we contemplate healthcare reform”

    A doctor who spent time to help me deal with SURVIVING cancer and the psychological impact it had on me told me that he had to make decision to no longer have me as patient because of long appointments. When I obtained encounter notes comments were written to justify the change (why he really could no longer have me as a patient) that were so damaging that I can say now it is worse then going through the cancer. Sickening. The actual encounters with the doctor were wonderful he never indicated otherwise he was warm and solicitous and embraced me. Now relationship destroyed. Shameful. At the best I hope he was being honest and did not have something else in mind. I am only going by what he told me in private and how I could still communicate with him. Please do not print my name or address.

  8. DrRich on February 17th, 2009 10:15 pm

    Anon,

    If it’s any consolation, what he told you in person about terminating the relationship is almost certainly the truth. What he wrote in his notes was for the regulators and the lawyers, since these are the individuals (along with the accountants) for whose needs our medical records are now designed.

    Rich

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