The Doctor—Patient Relationship 2022
The doctor-patient relationship is the central aspect of medical practice for physicians, but, as discussed previously, the relationship can be either transactional or relational. Arthur Derse, a physician and lawyer, has recently published a perspective on the history and current state of this core relationship.
“Today in the United States, the physician—patient relationship may be more fraught than ever, challenged as it is by greater emphasis on patient autonomy in the context of widespread misinformation and by external forces, constraints, and incentives not aimed at patient benefit.”
He notes the modern concept was defined about 120 years ago, initially in terms of a contract, but since the relationship was unequal, later expanded to include fiduciary aspects. What this means in lay terms is that physicians are legally required to act for the patient’s benefit, including maintaining confidentiality and non-abandonment. This was the state of things until the 1950’s, when the doctrine of informed consent to treatment began to be codified and recognized as an important aspect of the relationship. He notes “failure to provide adequate informed consent has since become a substantial domain for litigation.”
Modern medical practice has created occasional conflicts between the fiduciary responsibility to the individual patient and the needs of other patients. For instance, dialysis was not available widely when I was learning the art and science of medicine, and kidneys for transplant are still not widely available, creating an allocation issue and potential conflict. Allocation issues also arise in mass casualty situations where triage is necessary. But, as Dr. Derse notes, the issue did not arise for most physicians in regular practice until the pandemic began. Suddenly, many physicians had to think in terms of triage and allocation, and many were not psychologically prepared for it and experienced considerable moral distress.
As the pandemic persisted, and medicine did not seem to be stemming the tide of death and disability, popular enthusiasm for “snake oil” cures increased. This is not a new phenomenon. Consider “tonics,” or taking the waters, or, during my practice, laetrile for cancer and chelation therapy for atherosclerosis. As medical science brought forth more effective treatments that were readily available, demand for such unorthodox approaches retreated to the margins. Here, again, many practitioners were not prepared to have their faith in the scientific approach challenged, much less by public figures with no medical background. Many felt their erudition and training were being de-valued, which was certainly true in some cases. But, as the author notes, these are not the most prominent threats.
“Indeed, a prominent barrier to effective physician-patient relationships has long been financial conflicts of interest, arising from physicians’ ownership of health care facilities, for instance, or their receipt of financial incentives from industry. More recently, the increasing corporatization of the practice of medicine has created additional challenges. Corporations and insurers do not have the same fiduciary responsibility for patients that physicians have, and adverse corporate and insurer practices do not relieve physicians of liability for violating their duty…”
This is an issue we have considered from many angles in other articles, so I will not go into it further now. But it is an issue that continues to arise, particularly as decision makers get further removed from direct patient interaction.
Dr. Derse concludes by noting something that is relatively new—legislative directives on what can and can’t be discussed between physician and patient in the exam room. While the legislative changes following the Dobbs decision are an obvious immediate example, there are prohibitions on discussing risks of owning firearms in some states and on gender issues in others.
So, what can/should an ordinary physician do in this environment? I think the mandate is the same as always—it is our duty to establish a working relationship with patient to the best of our ability. If you don’t think you can do it, then you should refer the patient to someone else. I have long told the medical young that 5% of the population will adore you, 5% will detest you, and the other 90% will let you do what you have to do as long as you are polite about it. No one can care for 100% of the population and it is hubris to aspire to it.
Second, patient autonomy means patients are free to ignore, reject, or otherwise not adhere to your advice. Yes, the “non-compliant” patient hurts your scorecard, but everyone else has those patients, too. The goal with insurance/payer games is to be average, not perfect. Get over your need for an “A.”
Third, in the final analysis your best defense in the event of a lawsuit is being comfortable you gave the patient your best shot and that it was not different from the advice you give other people. If the insurance company won’t authorize the test that you think is important, make sure you inform the patient and let them decide what they want to do. The worst that can happen to you is you won’t get paid—but the worst that can happen to them may be far more dire. But bear in mind the uncertainty of all opinion, including yours.
Lastly, don’t “cop out” on giving the patient your opinion. Far too often, I have participated in counseling sessions where a physician asked “What do you want me to do?” We get paid to make recommendations. As long as we have acknowledged the limitations of knowledge and the risks of bias, patients and families need us to say “I would suggest doing this because…” If you are having open dialogue about the patient’s preferences, not yours, then you are living up to aspirations of a good doctor-patient relationship. Is this a perfect solution? No, but it will let you keep on doing the best you can in an uncertain world.
11 September 2022
 Derse AR. The Physician—Patient Relationship. NEJM 2022(Aug 25);387(8):669-672. doi:10.1056/NEJMp2201630.
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