Health 2.0

The Digital Age and the Doctor/Patient Relationship

The digital age has had a deep and likely permanent effect on the patient-physician relationship. I can’t tell you how many times I’ve had physicians beg me to provide them with a way to stop their patients from Googling their symptoms and diagnosing themselves before their first office visit and much to their chagrin, my answer is always the same, “You can’t stop them. Get over it.”

The internet acts as an enormous and easily accessible virtual research library for patients, granting them access on the one hand to quality, data-driven information and personal perspectives that can provide tremendous value and on the other hand to information that is no better than old-fashioned quackery.

But this access to information has not translated into improved interactions between patients and their physicians. It is clear to me that we all need help in rethinking how we can best work together, especially because I believe that we are still in the nascent stages of this age of disruptive new tools that delight some and threaten others. Time and time again I hear stories describing the ways in which this technology seems to be moving us backward instead of ahead:

· When Timothy B. Lee went to a dentist highly recommended on Yelp, he was asked to sign a “mutual privacy agreement” that would transfer ownership of any public commentary he might make in the future to the dentist.

· A TechDirt blog post reported that plastic surgeons have sued patients for their online negative reviews and a neurologist sued the son of a stroke victim for negative comments about the physician’s bedside manner.

Instead of pitting patient against doctor, these tools should be increasing our collaboration.

The days of the paternalistic family doctor who dispenses advice and counsel to an acquiescent, unquestioning patient are clearly over, but that needn’t be a bad thing.

Importantly, this issue features prominently in the new proposed CMS rules for accountable care organizations (ACOs) under the Affordable Care Act. An ACO is a network of doctors and hospitals that share responsibility for providing care to patients. ACOs play an important role in healthcare reform because they are intended to make providers jointly accountable for the health of their patients, providing them with strong incentives to cooperate and save money by avoiding unnecessary tests and procedures. While the focus of ACOs is collaboration at the provider level, the end game is all about the patient and increasing the quality of his or her healthcare experience.

In order for ACOs to qualify for shared savings, they must provide patient-centered care that is influenced by the patient autonomy movement. Before becoming CMS Administrator, Don Berwick wrote a provocative article in Health Affairs calling for a new definition of patient centered care as “the experience… of transparency, individualization, recognition, respect, dignity, and choice in all matters, without exception, related to one’s person, circumstances, and relationships in health care.”

In order to facilitate this shift, we need to resolve the current tension between the philosophy that idealizes the physician as always being right and patients’ newfound autonomy and access to information. We need to engage in a thoughtful discussion about how the new disruptive digital technologies can help both patients and physicians get what they need. After all, both have the same ultimate goals: good clinical outcomes and a meaningful relationship.

The good news is that these disruptive technologies can be the very mechanism we need to develop more accountable, quality-driven healthcare delivery systems because they can address some of the significant gaps in patient-physician communications that are so detrimental to the relationship. The Consumer Reports National Research Center conducted patient and provider surveys about the doctor/patient relationship and concluded that patients would get more from doctor office visits if they planned ahead, took notes during the appointments, and conducted careful online research for information. Other studies have shown that patients remember only about half of what physicians tell them during their visit and that 90 percent of patients receiving a new medication reported their physician never described the drug’s side effects. Perhaps most disturbing of all, more than 30 percent of patients were unable to name their diagnosis after being discharged.

Technology, far from being the villainous entities that so many care providers see, can actually improve a patient’s experience and address those disturbing statistics. Websites now provide patients with the tools to prepare for upcoming visits by listening to actual conversations between providers and patients that have the same diagnosis; they can organize their questions before the visit; they can record their visit using digital or mobile recording devices; and they can review the recording after the visit with caregivers and family members to better understand how they can partner with their physician’s advice.

For disruptive solutions to be successful, all of us must be willing to adapt the traditional doctor-patient relationship. Patients and physicians alike are confused and disoriented by the new digital world, even while being empowered by the knowledge they can impart. These cutting edge technologies have the potential to dramatically improve a patient’s healthcare experience, but to get there, we first have to engage in some good old fashioned talk.

Kent Bottles, MD, is past-Vice President and Chief Medical Officer of Iowa Health System (a $2 billionhealth care organization with 23 hospitals). He was responsible for the day-to-day operations of a large education and research organization in Michigan prior to his work with in Iowa with IHS. Kent posts frequently at his blog, Kent Bottles Private Views.

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13 replies »

  1. The best we can do is to advise our patients what the best web sites are to read. I usually give them a list of ‘trusted web sites’. Personally I find this a great way to interact and catch any misinformation that patients may have.

  2. My glasses are rose-colored. Literally. While it’s true that patients these days come in with hard-core “evidence-based” research downloaded via the net and attempt to hold their doctor’s $300,000 dollar professional degrees hostage against a random key word search, I think the problem actually lies within us, the very same docs who are railing against the machine.

    We’re not listening to our patients. No. We are not listening.

    Let’s examine this a little closer. In this day and age of busting bank accounts and money-gobbling health insurance companies, not to mention a global recession, it’s no wonder patients are doing one or more the of the following: a) wait until they are so sick they spend their last hard-earned dollar to visit a doctor and demand something they believe will work, or b) refuse to pay for recommended treatments by their doctors which just don’t seem to make sense anymore.

    Patients are sick of pills. They are getting sick of being tested like guinea pigs. They know something is terribly, terribly wrong with the system, with the government and with us, the automatons of the entire healthcare dilemma.

    Conventional medicine hasn’t delivered all the answers they seek. But they don’t know where else to turn, having been trained by the likes of us who say that it’s our way, or the highway.

    Through the eyes of most tunnel-visioned conventional doctors, we are still keeping our patients directed towards pills and fixes rather than offering better ways to actually heal. Even if it means we (oh my gosh) refer them practitioners in wellness rather than disease.

    No wonder our patients are turning to the internet anymore. They are sick of us. And we are keeping them sick. We have only to look to ourselves for this breakdown in communication and not continue to blame the forces of technological nature.
    If doctors were to accept that the internet is just a different information stream available to the public and then collaborate with their patients on the quality of that information rather than view it as an “age of disruptive new tools” I think we’d all be in a much better place. Don’t you?

    The word “utopia” comes to mind. But then again, my glasses are rose.

    Natasha Deonarain is double boarded in Family Practice and Urgent Care medicine, has practiced for eons and lives here:

  3. I understand that technology has made the doctor/patient relationship a difficult one, but I believe IT has more pros than cons. Although communication between patient and doctor is changing because of all of the information out there, it is the same for every industry. Instead of being afraid of technology, it is important to embrace it. That is why using EMRs is so important as well. Even if a person is using the Internet to self diagnose, EMRs will give both the patient and the physician an understanding of the patient’s history and help them come to a better conclusion together. I read a great article about how a collaborative health care system can be established that includes cooperation between the patient and the physician:

  4. “We are becoming more and more shallow as communications become more and more real time, and more and more served to you on a platter by your friendly and invisible marketer.”

    Couldn’t have said it any better.

  5. With the utmost respect for Dr. Weed and his pioneering work in health care, I disagree that health care is in any way comparable to transportation (and I did read the book).

    In the transportation world, the need is to get from an exactly defined point A to an equally well defined point B, by choosing one of a handful of available and well known methods. In health care, we know something about point A and point B is wishful thinking at best. The methods to go from A to B are many, or none at all, and defined in statistical terms which may or may not be applicable to a particular “traveler” and may or may not be agreed upon by those whose profession is to guide “travelers”.

    I don’t really care how much information the Internet makes available and how much it “dumbs down” medical content and how many other lay opinions are instantly available, there is no way a person can go through medical school in a few days prior to, or after, a doctor visit. Of course more people can get educated on their particular ailment now that you don’t need to go to a university library to dig through monographs and journals, but the number of people that have that ability has not changed much with the advent of the Internet.
    What the Internet does best is to serve you the lowdown on whatever ails you in 140 characters or less, and thus makes you an expert at nothing overnight. We are becoming more and more shallow as communications become more and more real time, and more and more served to you on a platter by your friendly and invisible marketer.

    As to patient-centered as defined by Dr. Berwick, it stands in stark contradiction to what ACOs, and everybody else from IOM to private payers, are planning to do to us, and I wrote about this before, at length, on this very blog (it’s not just about EHRs)

    I really think that patient-centered means absolutely nothing at this point. Certainly it has nothing to do with Dr. Berwick’s vision.

    • “I really think that patient-centered means absolutely nothing at this point”

      Actually, patient-centered has a very specific meaning: bigger profits for large insurers.

      If you want to get really depressed, read the proceedings of the latest Patient-Centered Primary Care Collaborative meeting. Way down, in small print, they finally mention those insignificant cogs in the machine, the doctors. We find that they experienced lower job satisfaction and increased “office chaos” when working in “medical homes.”

      Of course, the AAFP thinks this is great.

  6. bobbyG have already posted about Medicine in Denial on twitter but due to lack of chars, I have not put a link to this page!

  7. My hardcore friends at often refer sarcastically about “The University of Google Medical School.”

    Right now I’m reading the full book entitled “Medicine in Denial.” (It’s now available on Amazon).


    “…Like the transportation system, the health care system should be usable by ordinary consumers when feasible. In travel, rather than relying on professional taxi drivers, we learn to drive and we buy our own cars. Instead of hiring professional engineers to tell us what cars to buy, we read Consumer Reports and judge our personal needs and preferences for ourselves. Instead of hiring professional guides, we read maps and road
    signs. In some modes of travel (rail and air) we depend on expert service providers, but we as consumers, not those experts, choose the mode of travel. By comparison, if pilots had the authority that physicians have in the health care system, then pilots would decide when consumers travel by air, and unnecessary flights for short distances would be routine…”

    Interesting stuff.

    • BobbyG thanks for pointing us to an interesting book! The metaphor with transports is striking! Wonder why no one had thought of it before…
      Would rush to buy “Medicine in Denial”…
      This year I have read books that opened new windows on how we see health and healthcare, seems Medicine in Denial might be one… (my other readings “Tracking Medicine” by Prof. John Wennberg, “How Doctors Think” by Dr. Jerome Groopman, “Better Doctors, Better Patients, Better Decisions: Envisioning Health Care 2020” by Gerd Gigerenzer & J.A. Muir Gray)

  8. In order to facilitate this shift, we need to resolve the current tension between the philosophy that idealizes the physician as always being right and patients’ newfound autonomy and access to information. We need to engage in a thoughtful discussion about how the new disruptive digital technologies can help both patients and physicians get what they need. After all, both have the same ultimate goals: good clinical outcomes and a meaningful relationship.

    Dr. Bottles the above excerpt from your article says it all. There is nothing that can stop patients from trying to learn what is going on with the health problem they face. Doctors instead of complaining that patients come for their appointment already informed, they should offer help with trustworthy sources of information. Then, a discussion over the available options for the patient and his/her concerns would be much easier. We fear more what we don’t know than a risk we know about…

  9. I see points of truth in both opinions. As a practicing Physician I am happy with the improved facilitated conversation that results from my patient’s Internet research efforts.

    After all, “My patients don’t need to take my advice, they just need to pay the bill.”

  10. What I do not get after reading opinions like this across the internet for the past 10 or more years now is this: the patient-physician alliance is just that, the physician helping the patient figure out ways to help his/her self, and the patient respecting the expertise guiding a treatment plan but also giving the needed feedback to the doctor in ensuring the plan has the greatest likelihood of impacting positively, effectively. And yet, how does one know what websites that allegedly are in place to educate and empower patients about diagnosis and treatment options are unbiased and objective, not selling a specific treatment intervention, or worse, badmouth other interventions, if not just minimize physician care. Come on, you all really think the internet is mostly transparent and genuine in 2011? Some of it is, but I don’t think that even 50% is about the patient first. Again, not a Luddite, but also not a mindless assimilate either!

    But, as far as I am concerned, all the internet and immediate feedback technology has done for the past 10 or more years is foster this entitled, quick fix, “holier than thou” attitude that is too frequently siiting across the office at me from moment one. No, it is not everybody I interact with in the office, and equally I am not too eager to engage a patient who is overly dependent on every word and idea I offer either.

    I really think that the dynamic most of my colleagues who have become doctors in the past 15 to 30 or so years, prior to this internet mentality growing hold in the culture, is we want to help patients and expect them to focus on how to help themselves by making changes and educating outside the office on what the provisional diagnosis and treatment options are at moment one of care. Then should the diagnosis need to change, so will the focus and needs to keep the patient moving forward to maintaining/regaining health, to be functional and productive in their daily needs and pursuits.

    Having had a patient come in my office last week, then call me the following Saturday morning and literally argue over the phone for 15 minutes that what she read on the internet trumped what I spoke to her about in the office was just rude in the end. Her “facts” did not fit her presentation and intervention plans, but, to her, some nameless, faceless commenter had all the answers and plan of action. Good luck to her and all who embrace that kind of mentality.

    You know what I believe at the end of the day? The doctors who are selling the internet and full use of technology are either minimally practicing clinical care, or are not trained to treat people, just diseases that fit algorithms.

    Keep this up colleagues, and my sarcastic scenario noted in a prior thread will be true, patients will just walk up to some robotic type device and after being “scanned”, a piece of paper will be spit out denoting the problem and treatment recipe. Yeah, I like that word “recipe”, cookbook medicine at it’s finest!!!

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