In a recent Harvard Business Review article, authors Erin Sullivan and Andy Ellner take a stand against the “outcomes theory of value,” advanced by such economists as Michael Porter and Robert Kaplan who believe that in order to “properly manage value, both outcomes and cost must be measured at the patient level.”
In contrast, Sullivan and Ellner point out that medical care is first of all a matter of relationships:
With over 50% of primary care providers believing that efforts to measure quality-related outcomes actually make quality worse, it seems there may be something missing from the equation. Relationships may be the key…Kurt Stange, an expert in family medicine and health systems, calls relationships “the antidote to an increasingly fragmented and depersonalized health care system.”
In their article, Sullivan and Ellner describe three success stories of practice models where an emphasis on relationships led to better care.
But in describing these successes, do the authors undermine their own argument? For in order to identify the quality of the care provided, they point to improvements in patient satisfaction surveys in one case, decreased rates of readmission in another, and fewer ER visits and hospitalizations in the third. In other words…outcomes!
Perhaps sensing the difficulty of their position, Sullivan and Ellner conclude the article on a more sober note:
If we believe that relationships are key to value, how should we be measuring them? The good news is that we have role models: Some practices are already doing this. The bad news is that each one is different, specific to its patients’ and community’s needs. But maybe that’s not so bad. After all, every relationship is different.
Yes, “every relationships is different,” and for the most part, healthcare economists and policy makers have paid scant attention to the doctor-patient relationship except in two opposing respects.
On the one hand, Nobel prize winner Kenneth Arrow and his followers have emphasized the “asymmetry of information” between doctor and patient. According to them, the lopsidedness between the knowledge of doctors and the ignorance of patients is so great as to render patients helpless. Government must intervene in the healthcare market to redress the imbalance of power.
On the other hand, and against the paternalism of Arrow’s view, a “consumer-driven healthcare” movement has emerged according to which patients should have more choice in the kind of care they receive. This choice will occur if patients manifest greater financial responsibility in their medical care through the use of health-savings accounts and high-deductible health insurance. With such measures, it is argued, healthcare would behave more like a free market, costs would decrease, and quality would improve.
While both models seem at odds with one another, both commit the same conceptual error of considering that the primary function of the doctor is to supply an objective service. Hence, neither school has any qualms with identifying the doctor as a “provider.”
But to limit medical care as a “provision” of services greatly misunderstands the complex reality of the therapeutic relationship.
Almost 60 years ago, Szasz and Hollender pointed out that there are three aspects to the doctor patient-relationship: activity-passivity (doctor does “something” to patients); guidance-cooperation (doctor tells patients what to do); mutual participation (doctor helps patients help themselves).¹
All three aspects are operative, but one may dominate the others depending on the particular circumstances at a given time.
Accordingly, a cardiologist may be “doing” a coronary stent at one point, yet for months prior to that she may have been—perhaps begrudgingly—cooperating with the patient’s desire to avoid taking a statin. And she may spend the next years coaching the patient on best ways to cope with statin-induced muscle pains and to adjust to difficult dietary restrictions.
Of course, all these aspects of care are rendered with great uncertainty as to the particular patient’s ultimate outcome, and parsing the importance of each aspect of care in relation to an uncertain outcome is anyone’s guess.
The first aspect of the doctor-patient relationship (the “activity-passivity” mode) is the only one that policy makers and health economists typically consider, precisely because it involves a “something” that doctors do to patients. That something can (theoretically) be objectively observed, analyzed—and measured by third parties. But in ignoring the other two aspects of the relationship, one inevitably distorts the whole picture of what healthcare is about.
And Szazs and Hollender’s account of the therapeutic relationship may even be too simplistic. Yes, doctors do things to patients, guide them, or help them help themselves. But they may also humor them, scold them, or ignore them altogether, and each action may be appropriate in its own context.
And conversely, patients act on doctors. They can show gratitude (in a variety of ways), and thus enrich them on a personal level. But they can also question them, challenge them, refuse their advice, and keep them on the straight-and-narrow, all-the-while remaining committed to that relationship despite any limitation they may perceive about the care they are receiving.
In truth, a good therapeutic relationship is precisely undergirded by this mutual commitment, where the one will not abandon the other for failing to follow through with the prescribe course of action, and the other will not ditch the one for failing to “deliver” outcomes everyone knows are unpredictable.
Relationships based on commitment are neither captured by the expert-subject model, which primarily focuses on the skills and science of the all-knowing physician, nor by the businessman-customer model, which focuses on how physicians can aim to please patients.
No, the committed therapeutic relationship is truly one of friendship. And any person, entity, or policy that overlooks the friendship aspect of medicine is sure to inhibit, if not altogether destroy, the essence of what good medical care is all about.
Will outcome enthusiasts take stock of the likely outcome of their own enterprise?
NOTE: 1. I am grateful to Margalit Gur-Arie for bringing this paper to my attention in her excellent recent post on measuring the doctor-patient relationship.
For further reading about friendship in medicine, you may wish to consult Edmund Pellegrino and David Thomasma’s A Philosophical Basis for Medical Practice: Toward a Philosophy and Ethics of the Medical Professions (Oxford University Press, 1981) or The Health Care Professional as Friend and Healer:Building on the Work of Edmund D. Pellegrino (David Thomasma and Judith Kissell, eds. Georgetown University Press, 1997).
“No, the committed therapeutic relationship is truly one of friendship.”
I shadowed two general practitioners in medical school. One worked in the posh zip code of Pimlico, London. The other in the more down to earth Brixton.
Both were excellent. But I doubt the approach of the GP in Brixton would work in Pimlico. And the GP in Pimlico would probably go in to major depression in Brixton.
The only general rule that I have found useful in medicine is “it depends.”
Thanks, Saurabh. I did not elaborate here on the meaning of friendship. I think we have come to think about friendship in narrower terms than the concept deserves. Also, you’re right; it’s the nature of friendship to adapt to circumstances, and none of us know how to be good friends at all times in all places.
Friends trust each other to a point lacking critical questioning. I think it’s counter to quality care to trust your doctor unquestionably.
Think about how friendships work. Friends are allowed to ask questions. They’re also allowed to challenge, at least in true friendships.
This came up in a conversation I had the other day with a very smart doc I know. My doctor friend observed that there are currently two dominant types of “patient personality” types.
One wants the old doctor-patient relationship. Another wants a participatory and democratic relationship.
In reality people are somewhere between the two points on the line.
There are two kinds of doctors. Those who are willing to engage in the a new kind of participatory relationship and those who prefer a more traditional approach – for whatever reason.
It is simplistic to say that those who hestitate to embrace a more participatory relationship are backward and wrong. There are other factors involved. Specialty, generation of physician, generation of patient population, demorgraphics of patient population.
So the answer? Well … it’s complicated.
But I think we’re getting there!
In reality you have to adjust your style to the patient. Many patients will say, “just tell me what to do, or you’re the doctor”. Others are happy to mull over choices and many different recommendations, and many will mirror back to me information they have seen on Dr Google.
If you want to practice in today’s environment, you have to be very flexible.
If you want to know what approach to definitely avoid, watch BBC’s Doc Martin. He’s a brilliant doctor, but his bedside manner is appalling. However, if you’re having a crisis, he could save your life.
How can the doctor be a “true” friend when his invisible lawyer friend is perched on his left shoulder.
I believe that what Erin Sullivan and Andy Sellner are saying is not to focus on a general approach to arrive at a desired outcome, but to develop a relationship that in the end will facilitate the ability to achieve the desired outcome for an individual patient. In other words, the relationship is the basis for the outcome. A patient knows that a physician who cares and will be available to them within an appropriate time span will be less apt to go to the ER for non urgent issues. Doctors and patients play all of the roles of activity-passivity, guidance-cooperation, and mutual participation just as all individuals do in many different relationships. Having practiced medicine as an Internist for many years, the relationship will determine how well you achieve your outcomes.
I am certainly sympathetic to and in general agreement with the viewpoint of Sullivan and Ellner (note: I mistakenly gave his name as Sellner), and perhaps my article makes me seem too critical. But one point worth emphasizing is that the value of relationship is inherently subjective and unmeasurable by outsiders. In some aspects (though not all), the relationship is the outcome.