Doctor-Patient Relationship:"Be a Fountain and Not a Drain"
“Be a fountain not a drain”, an expression used by baseball announcer Rex Hudler is one that has motivational content particularly in terms of an individual included as part of a team. I would suggest that this expression would be appropriate when considering a basic team in medical practice: the doctor-patient relationship. As I have noted repeatedly throughout a number of threads in the past on my blog, it is critical in most clinical situations that both the doctor and the patient assume responsibility for making progress toward the goal of diagnosis and therapy and hopefully a cure. The doctor-patient relationship is not one of the patients simply “taking” or “draining” the knowledge and skills of the physician or one of the doctor simply “spouting” those capacities to the patient. Each member of this team has a responsibility to contribute and not just “take”. That means that the patient must realize that the doctor can usually fail to make a diagnosis without a full history provided by the patient. It also means that to examine the patient, a certain degree of patient cooperation is required for the exam to be of value. And when it comes to treatment, patient compliance is also essential. On the other hand, the physician should understand that looking at the patient simply as an “object” of a disease and a resource to demonstrate one’s skills for an income is not what the doctor-patient relationship is all about. It is not about “taking” but is about considering the patient as a “subject” of physical and mental concerns giving the patient not only a chance to be physically healthy but also a feeling of comfort in the relationship and support of the patient’s emotional health.
Now, one may argue that the doctor-patient relationship is not really a equally balanced one in that it is the patient who is sick and may be ignorant of the facts of the illness and treatment whereas the doctor is not. Therefore, it should be only the doctor who should be required to be the “fountain” and, well, the patient receiving and taking the results, the “drain”.
Which view do you hold? ..Maurice.
posted by Maurice Bernstein, M.D. @ 9:21:00 AM
11 comments
11 Comments:
Intellectually, I have to say that its critical for patients and doctors to be in a fully dynamic relationship, with meaningful two-way interactions, for there to be any lasting benefit from the interaction. Practically, however, when I am at my doctors office for a check-up or an appointment its much more difficult to make this a reality.
Speaking for myself, I have yet to visit my doctors office without it being, for lack of a better expression, an inconvenience. The fact of the matter is that most of the time you'd much rather be somewhere else and doing something else than talking to your doctor. Health problems are, after all, impediments to what we really want to do with our time and effort. So it requires a good deal of forethought and future-oriented thinking to get past the feeling that you just want to get it over with as quickly as possible and actually make the investment into the interaction to make it a more meaningful relationship. It pays off in the long run, we probably have hard data to prove it, but we humans are notoriously bad at thinking about the long run.
Dmitri, I put this topic on a bioethics listserv. An ethicist responded with a comment which reinforces your concern about the "reality" of a simple doctor-patient relationship. The ethicist wrote:
Problems with discussions of THE doctor patient relationship:
The term suggests that there is a single doc and a single patient who sustain a singular relationship between them. In fact, however, few patients see the same doc all the time. Some have no specific doc at all, many are in team practice
where they never know whom they will see, patients move, docs move, multiple specialists are involved, etc.). Patient and doc do not
typically work or even meet as a single duo: family members, nurses, may be present; others are generally involved in their care. Even when a doc and a pt. meet w/o presence of others, each brings to their meeting many other
relationships, both personal and professional, that affect the interaction. Talking about THE doctor patient relationship as if it is singular or unique obscures the inevitable complexity of (inevitably plural) human relationships. In recognition of this complexity, some doc may someday write a piece for the NEJM entitled The Myth of THE Doctor
Patient Relationship.
..Maurice.
The first thing that struck me was your use of the word "compliance". I understand that there is somewhat of a movement to remove that from the discussion of a doctor-patient relationship. I know the word immediately gets my back up.
As the patient, I do not believe that my role is to "comply". The doctor's role is to use his knowledge to recommend, and mine is to decide if I'm going to go along with that recommendation. If I believe the doctor is competant, and has my best interests at heart, I probably will. Perhaps after doing a bit of my own research first.
I'm sure that is not a view you like to hear - and I don't blame you. But, not all doctors are equal, and even the best can make mistakes. And it's my body, my life, and I believe, my decision.
Frankly, the physician is getting paid. That's what he gets out of the relationship. And hopefully some professional satisfaction. The patient (or their insurance company) gets to spout forth his salary.
The patient gets to take from the physicians knowledge.
Now, no one can do a good job with their hands tied behind their back. If the patient doesn't give a complete history, and won't do anything the doctor says, well the fountain will run dry or foul tasting for that patient.
However - history taking is quite a skill. I know quite a few people who aren't capable of giving a good history. The physician has to ask the right questions, and guide the patient often times. Of course, if the patient doesn't tell the truth, there's nothing the physician can do about that.
Also, it can be very hard to get physicians to listen to a patient. Some have the attitude that the patient doesn't have much worthwhile to say, they are so much smarter. In that case, they are only capable of "spouting". I do understand the problem of time constraints though.
When there is true teamwork, and I have experienced this, it really works out very well - both contribute to the end result.
TAM
TAM, good analysis. I should point out that "compliance" is really a complex activity or response to a medical decision. Of course, following a therapeutic regimen is the responsibility of the patient after agreeing with the physician's advice on the value and risks of the regimen. Where compliance gets undone is when the patient later finds that the cost of the medication is too expensive for the patient's budget and doesn't buy the drug, that the timing of the pill taking is inappropriate for the patient's life style and doesn't take the medication as prescribed, that some side-effect to the medication appeared and the patient stops the medication and so on. What defines "lack of compliance" occurs when a patient fails to notify the physician in advance of a visit about these issues, which could have been attended to and mitigated by the physician if made aware, but later returns either not revealing to the doctor that the medication was not taken or as directed and tells the doctor nothing. Thus, the doctor may be assuming the patient has been following the treatment decision fully. Full communication with the doctor about the therapy following the decision is a critical aspect of compliance. ..Maurice.
Maurice, I agree entirely with what you have said. But I think the medical profession needs to pick a different word. When I hear "compliance", I think that I just have to do it, whether or not I like it, or have intolerable side effects, or whatever, because the doctor "ordered" it. Obviously, that is not what you mean - but that's how I think it may sound to the layperson.
To see if I was getting my back up incorrectly, I looked up the dictionary.com definition of compliance:
1. the act of conforming, acquiescing, or yielding.
2. a tendency to yield readily to others, especially in a weak and subservient way.
3. conformity; accordance: in compliance with orders.
Given that definition, that's something I'm not willing to do. It does, however, fit the old "paternalistic" style of medicine.
Given your definition - sure, I'd go along with that. Communication is key. But, I still think, given the changes these days, getting away from the paternalistic style of medicine, you all need a different word.
TAM
TAM, unfortunately "compliance" is the word that is used but to doctors it also includes "communication". The doctors expect the patient to communicate with them their concerns. Unfortunately, I think most doctors don't go into a introductory session with the new patient regarding what they expect from the patient and so the patient may be unaware that the doctor expects compliance with regard to full communication. I think we doctors don't start out with a lecture to the ill patient because of time but also because we first want to attend to the patient's needs rather than our professional expectations of the patient's behavior. I am sure that is why we don't also go into any discussion of patient modesty issues in the meeting. Sometimes, we doctors are naive in thinking that the patient will tell us "everything".
With regard to medication compliance, I personally ask each of my patients at a visit whether they are taking all their medications and as directed and I may ask whether specific side-effects have occurred.
I think doctors have to take the initiative in establishing patient compliance. ..Maurice.
I think the physician taking the initiative is a great idea.
When prescribing a medication, it seems like it might be a good idea to say something like "Now, most people tolerate this medication just fine. But very occasionally, there can be an unpleasant side effect. If, for any reason (cost, side effect, etc.) you won't be able to take this medication like it's prescribed, please call me right away so that we can figure out something else that will work for you."
Many people hesitate to "bother" the doctor, and will just wait until the next appointment. Or, they feel the doctor won't care if they don't like the medication, so don't communicate it.
I would suggest that the physician mention his/her willingness to hear from the patient, and adjust the treatment plan if necessary.
I've watched the "don't like it, not taking it" performance from an old lady, many a time. I do understand that probably drives the physician nuts.
TAM
The doctor - patient relationship is a joining of mutual trust developed over time. It is the essence of medicine (health care).
What the ethicist said is true but is certainly not the complete story. The group of "others that are generally involved in their care" exists to support and serve the effective functioning of the doctor - patient relationship. The reality of "team practice" can undermine an effective relationship, and both doctors and patients should make the effort to maintain their unique relationship. Regarding "multiple specialists," it generally becomes clear which specialty is most encompassing for that individual patient. Then, that doctor should take over the case, manage it incuding "primary care," and, with the patient, develop a sound, ongoing, non-conflicted doctor - patient relationship. Isn't it interesting that patient care is divided into "primary" and "specialty" categories?
Patient "compliance" means following the plan of Dx and Rx that he/she PARTICIPATECD IN DEVELOPING with the doctor.
Sound, ongoing, non-conflicted doctor - patient relationships are indeed on the wane. This loss has several causes beyond doctors' control. But they boil down to efforts by the "business of medicine" to tear asunder this relationship. If successful, then the businesses themselves will control the practice of medicine. Herding patients into primary care holding pens is one of their business mechanisms.
A return of belief in and actual existence of sound, ongoing, non-conflicted doctor - patient relationships is THE FUNDAMENTAL REQUIREMENT for true healthcare reform in the USA.
R. Garth Kirkwood,MD
www.equalhealthcare.org
doctork@equalhealthcare.org
Garth, several thoughts in response to your post.
First, often the healthcare "team" - from receptionist, to nurse, to PA, often seem to view it as their job to protect the doctor from the pesky patient. Actually getting to speak to the doctor outside an appointment can be difficult to impossible. Again, I understand the time constraints, but not every patient does. Often requests to speak to the actual doctor are met with great resistance.
Secondly, I've almost never seen a plan developed between patient and doctor. The doctor listens (hopefully), examines the patient, and says "I'm going to put you on such-and-such medication" and hands the patient a prescription. Rarely is there a discussion of what the medication is, how it works, or anything else. I've been to many a doctor's appointment (I took care of an elderly lady among other folks) and not ONCE did a doctor mention a potential side effect. Ever.
So the patient takes the script and looks at it, by which time the doctor has usually zipped out the door.
Once they actually fill the medication, THEN they might see the list of side effects. Or they take the drug, and get the side effect.
Then they *might* call the office, at which point the staff attempts to keep them from talking to the physician.
Now, I'm not saying this is the way it is with every physician or practice. But I am saying it's that way a lot.
TAM
You may be interested to know that this thread has been published today on the KevinMD website and can be accessed to read the comments of others by clicking the following URL http://www.kevinmd.com/blog/2011/08/patients-contribute-doctors.html ..Maurice.
I just wrote the following comment to the KevinMD website:
The question is what should society and the medical profession do to encourage patients that their job in furthering their quest for relief and cure is beyond the now fully ethically and legally supported autonomous decision-making but to feel free to speak (not "speak up" but speak) to their doctors as a person who also "knows facts" that the doctor should be made aware. The facts will be their own personal history but also the facts that they have gathered through their own research. Sadly, what can be done about this is inhibited by the way medical practice is practiced these days: rush and no time to LISTEN. Who spends an hour with the patient.. how about a half hour? And can the patient say "wait! I have something to say"? Time, yes, the looking at the time and readying for the next patient is the current medical practice "spigot" which is turning off the patient to become a "fountain". ..Maurice.
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