Why Has the Doctor-Patient Relationship Suffered?

Doctors didn't go into medicine to treat consumers. They were never asked "why do you want to be a provider?" when applying to medical school. Patients, similarly, want to be treated as human beings, not like customers at a kiosk. Unfortunately, this phenomenon highlights the suffering doctor-patient relationship and portends a poor trajectory for modern medicine.

The simple truth is that doctors want to treat and patients want to be treated. While there exist individuals in every profession with misaligned interests, an overwhelming majority of physicians didn't rack up thousands of dollars in debt and forego the majority of their youth studying "how to provide for consumers." Why did we start using the terms consumers and providers, and what does this mean for the doctor-patient relationship?

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The change in terminology is an unfortunate consequence of the change in perception of the health care industry. Twenty years ago, before spiraling costs and patient complaints came to the surface, medicine was a standalone entity distinct from "business." Today, health care has unfortunately earned notoriety for being the nation's most costly industry in desperate need of an overhaul.

With the re-cataloging of medicine as a business, the field has opened up to the application of standard business administration principles from executive leadership. The first step was to identify the players and their respective roles within the system. We unanimously believed patients to be the consumers and physicians to be the providers. This is where we went wrong.

For the health care worker, day-to-day practice and activities are centered wholly on the patient. This perspective leads to excellent individualized care - the very same world-class care that brings patients from around the world to the best American hospitals - but not necessarily appropriate systems-based care. Thus, when leadership asked health care professionals to identify who the "consumers" and the "providers" were, it was understandable but hasty when we cemented patients as the consumers and physicians as the providers. Day-to-day and systems-based roles are not always the same.

Two fundamental problems arise as a result of this mislabeling. First, we overstate the physician's ability to impact systems-based metrics like cost and outcomes resulting in misguided and prohibitive regulations of day-to-day practice. Second, we dehumanize the patient condition and run the risk of failing to act in his or her best interest. Together these two trends sap the doctor-patient relationship.

While the physician does quarterback the delivery of medical care, this is vastly different from quarterbacking system care. Numerous system-related factors extrinsic to the physician must be in place to actually practice medicine. From physical facilities and diagnostic tools to basic electronic health record software, many factors must be aligned for a physician to perform the job. Compared to the "provider" in a traditional business sense, physicians are in far less control of the environment with which they administer care. Furthermore, the "provider" label has permitted the unexpected consequence of suffocating physician oversight and regulation in day-to-day care. Bearing the burden of being a provider comes with the administrative responsibility of documenting patient encounters in complex detail, attributing obscure billing codes, and constantly adapting to software systems with less "meaningful use" than the next. These distracting factors have come at the expense of individualized care.

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While it is difficult to swallow that we have chosen quantity over quality care without overwhelming evidence in favor of this approach, a greater concern is a loss of patient empathy with the term "consumer." Today, many young physicians are incentivized to average eight minutes or less with the patient. For many, these eight minutes have become more like a Genius Bar appointment at the Apple Store with attention split between the patient and a checkbox list of questions on a screen. A troubling corollary in this consumer-centric approach is administering care with the belief that the "customer is always right." This philosophy does not translate in medicine since not all patients are familiar with their options; thus, arriving at decisions together as a team is vital in maintaining a successful patient-physician relationship.

Health care in the United States has earned its reputation for leaving patients, physicians, and governments dissatisfied, bankrupt, or both. Reform has facilitated political and administrative changes to address the seemingly endless list of issues, but one underlying problem still contributing to broad dissatisfaction is the diminished doctor-patient relationship. The root cause for this recent strain stems from poor identification of system-level roles. As such, we must redefine how we view all of health care's players and refrain from referring to our physicians as "providers" and our patients as "consumers."

Both patients and physicians are at the mercy of external factors to achieve their goals of recovering and treating, respectively. Thus, both deserve to be labeled "consumers" and be treated as such. Since "providers" in the traditional sense establish the boundaries for what customers receive, federal regulations and health payers deserve this role as the true determinants of what patients and physicians can or cannot do.

The first step in revamping American medicine requires an intimate understanding of the players, their roles, and more importantly their system-level capabilities. To date, overvaluing physician impact and undervaluing the patient condition has snowballed into a prohibitive culture in day-to-day medicine that distracts us from addressing systemic flaws and preserving the sacred doctor-patient relationship.