The Decline and Fall of the Doctor-Patient Relationship

The physician-patient relationship is a bedrock of the U.S. health system. Strong relationships are associated with higher ratings for physicians and better outcomes for patients but there’s a catch.

In Secretary of Health and Human Services’ Tom Price Senate confirmation and many times since, he has vowed his administration will seek to restore that relationship. But what patients associate with a strong relationship is increasingly at odds with how physicians think. And the gap between the two seems to be widening.


Per the American Medical Association, the physician-patient relationship is a formal or inferred relationship between a physician and a patient, which is established once the physician assumes or undertakes the medical care or treatment of a patient. It is a responsibility physicians don’t take lightly and most believe they do it well.

The physician-patient relationship has been widely studied. A framework developed by Ezekiel and Linda Manuel has been widely used to categorize the four roles physician play in these relationships: guardian, technical expert, counselor, and friend. In interacting with patients, physicians play all four. Researchers have linked a physician’s personality with their bedside manner. Surveys show most physicians lean toward a more paternalistic approach in dealing with patients and the majority think friendships with patients must be approached with caution. Academics have studied the dynamic between physicians and patients, observing that the physician is the ‘power’ figure in most. Studies have linked a physician known to have a prickly personality with more patient complaints and, in some specialties, a higher susceptibility to lawsuits. And physicians routinely compare notes among themselves about problem patients with whom interactions are routinely difficult.

Through the years, the American Medical Association and every major medical organization have opined consistently to the need for strong physician-patient relationships. Physicians understand their importance: they’re pragmatists. They understand that a pleasant bedside manner is not necessarily correlated to clinical competency and skillfulness but both are important. They are sensitive to impressions that their profession attracts smart people with big ego’s and a predisposition toward arrogance. And they recognize that changes in their environment are driving a wedge between how they practice and the expectations patients have for the relationship. Consider:

More physicians are now practicing in larger groups, and one third are employed in hospitals (MGMA). That means the clinical judgement of a clinician often is part of a larger scheme for managing patients consistently (to optimize clinical coordination) and efficiently (to maximize productivity and revenues). Peer reviews, utilization management and comparative effectiveness are now part of their lexicon.

Data about the quality of a physician’s care is increasingly accessible to patients from independent third-parties that sponsor report cards about physician outcomes, practice patterns and ratings by patients. It’s a growing irritant to physicians, especially those that believe the measures used are neither valid or reliable.
The science of medicine—what works, what doesn’t and for which patients—is increasingly accessible to patients seeking information about treatments that might not be recommended by their physician. The democratization of medical knowledge via social media and readily accessible clinical guidelines from reputable sources means patients have more questions and are often armed with inaccurate or harmful information.
Physician income pressures are mounting. Granted, their incomes remain healthy compared to the overall population ranging from 3:1 up to 20:1 but physicians face higher administrative costs and lower reimbursement from employers and insurers. There’s almost universal belief among physicians they’re fairly paid and palpable fear things are getting worse. And they react viscerally to the notion that physician greed is systemic.

And physicians understand that ratings by patients are here to stay. Patients expect to be able to compare the quality of medical care they receive just as they compare every other high-profile profession. And physicians know their ratings matter to payers like Medicare who penalize them for poor patient experience ratings.

Against this backdrop, most physicians believe their relationships with patients are less than ideal due to circumstances beyond their control. The majority think the profession is being compromised by external intrusions that limit their effectiveness as clinicians and compromise their relationships with patients. They want to spend more time with patients but recognize the gap between their wishes and reality is widening.

Patients see a gap, but their perspective is different. They see their physicians in positions of power and trust who are highly compensated and knowledgeable. They do not understand the complexities of modern medical practice nor do they believe them insurmountable. Their wish list is simple:

  • Most patients trust their physicians’ judgement but want a second opinion for major treatments and decisions, and they pursue those on their own.
  • Most want to learn more about their condition from sources that are evidence-based and independent.
  • Most believe they should have complete access to their own medical record without cost or hassle.
  • Most think their physicians should leverage online technologies to allow online scheduling, tele-visits, secure messaging and more. (Most practices permit online bill payment and little more).
  • Most want their physicians to embrace alternative therapies and lifestyle interventions in their recommendations.
  • All want their physician to tell them what a procedure or encounter will cost ahead of time to avoid surprises.
  • All want to know their physician’s track record—outcomes, patient ratings, and more.
  • All want their clinicians to disclose their conflicts of interest i.e. business relationships influence their referrals.
  • All want their physicians to treat them with respect and listen better.
  • All think their practices should provide better service that’s convenient, accessible and person-centered.Little wonder half of all patients say they are open to making a change. Most think physicians are focused on their own needs rather than theirs.

What’s Ahead for Physician-Patient Relationships?

Four trends will reshape physician-patient relationships:

Practice settings: Physicians will increasingly be affiliated with larger groups that position themselves around their depth, breadth, service, prices and reputation.

Financial Incentives: Physicians and patients will share financial risks associated with health insurance plans, and Medicare will penalize physicians that do not score at acceptable patient satisfaction levels. In other words, physicians will have an incentive to manage a patient relationship rather than accommodate visits and requests.

Data: An abundance of valid and reliable data will be available to consumers to compare the performance of their physicians about outcomes, practice patterns, financial relationships, patient experiences and costs.

Insurance Design: Patients will have more skin in the game. Employers are shifting financial responsibility to employees via high deductible plans; Medicaid is shifting to managed Medicaid and Medicare is encouraging alternative payment programs.
The combined impact of these means physician-patient relationships will be better coordinated, managed tightly and the basis for differentiating the performance of medical practices. Patients will migrate to practices that put their needs and values first.

The gap in the physician- patient relationship is widening. It’s clear patients want something quite different than they’re getting. Both perspectives are important and neither more than the other. So as Secretary Price and others espouse the centricity of the physician-patient relationship, it’s important it be understood objectively.


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12 replies »

  1. I am commenting from the stand point of a patient. I don’t know all the ins and outs of your industry, and I would imagine that making decisions regarding someone’s life has to be insurmountable at times.

    My two experiences with both of my wives has been an education for me on a number of levels, especially in terms of the systemwide issues that all of us face.

    My first wife died of cancer, and The doctor we had at first practiced playing the safe route on every decision that he made. Further, he argued with every decision that we were thinking of making. He ended up getting fired.

    The second situation is with my new wife, we have had some challenges with having a child due to known issues such as our age (late thirties). Ever since we have been treated by her doctor, the doctor has spent more time defending her credibility and liability than treating the patient.

    It seems that all opinions shared in this particular forum point to a couple of different and observable problems. However, as a patient, I don’t care what qualifications someone has, it does not overturn the thoughts and feelings of the patient. While none of us can change the system, the ability to listen and understand a patient is a choice. I think if both doctors that my wives saw did this effectively, I would not have issues with either of them… even if bad news was delivered.

  2. Please forgive my ignorance, but where is that patient wish list coming from?

  3. Yes, that would be Bob Doherty, who makes all of us pretty angry every time he posts on KevinMD. He is so busy telling us what to do, he can’t imagine anyone ignoring his helpful “ethical” instruction on DPC. BTW, he blocked most of us on Twitter… if you are and independent doc, he doesn’t want to hear from you.

  4. Our organizations have sold us out. The AAFP is finally coming around some on DPC, but I still don’t think they quite get it.
    One of the ACP honchos who is actually not even a doc has posted on Kevin MD questioning the ethics of DPC.

  5. Upon a re-read of the post, I am not sure about the patient “wish list” that Paul Keckley described. Ultimately, the true underlying theme for most people is a desire to share a trustworthy relationship with a physician and their healthcare team. In a crisis, its the only attribute that really matters.

  6. I agree and unfortunately the major “physician” organizations continue to fight for “coverage” and encourage docs to work for hospital owned practices. I’m not sure why, but the AMA, AAFP, and other organizations don’t represent most of us and certainly don’t lobby for common sense solutions to this mess.

  7. In my experience–5 yrs hospital employed, 3 yrs PCMH employed, 2 yrs owning own Direct Primary Care practice–direct pay is the solution. Insurance should go back to being insurance, not managed care with mandated benefits. I offer my patients affordable, accessible care and they love it. Everyone deserves healthcare like that provided by DPC. For more info http://www.bluegrassfamilywellness.com Molly Rutherford, MD, MPH

  8. We are guilty of two glaring sins and until we fix these, the patients should distrust us:

    We can’t have patients pouring all their money into insurance products, the manuals for which take a week to read and weigh 2 pounds–and ongoing explanations of benefits that are impossible to understand.

    We can’t continue to sit by and allow hospitals to confuse patients by their everlasting Byzantine paperwork either…apparently deliberately designed to prevent understanding of prices.

    If we don’t have the political clout to fix these, then we should
    see that we are politically defective and work to get it. There is just too much money being sucked from our patients to tolerate all this deliberate obfuscation of clarity.

    We have to decide whether we are patients’ agents or not. Our patients are being assaulted.

  9. It is likely that a recurring theme within health care and healthcare is the level of cognitive dissonance that occurs among its individual and institutional participants as they interact to solve the social dilemmas that regularly characterize these relationships. Driving all of this is the evolving decline in the prevalence of social capital, community by community. I would suggest a couple of strategies for anyone interested in the concept of SOCIAL CAPITAL. Read the little book “BOWLING ALONE” written by Robert D. Putnam and first published in 2000 with an annotated version released earlier this year by MACAT.
    As a personal gesture, I would also suggest that “health care,” aka encounter, is a variant of a Caring Relationship that forms the basis for parents, spouses, relatives, neighbors, teachers, pastors, et cetera. A CARING RELATIONSHIP may be defined as a variably asymmetric interaction between two persons who share a ‘beneficent’ intent to enhance each other’s ‘autonomy’ by communicating with warmth, non-critical acceptance, honesty and empathy. For health care, ‘beneficence’ is usually coined as “do no harm,” and ‘autonomy’ as “avoiding co-dependency.” These relationships formed initially before a person’s birth then become the basis for a family’s bonding networks with neighbors and extended family as well as referral networks for survival during a person’s lifetime.
    Since the end of WWII, the mobility of our society and the rapidly evolving scientific level of knowledge has interacted with our nation’s ethnic diversity to increasingly disintegrate the stability of families and neighborhoods, the resulting decline in our nation’s social capital. As a basis to understand the underlying chaos for our times, I offer a definition of SOCIAL CAPITAL. Social Capital may be defined as the spontaneous expression of collaboration, reciprocity and trust for resolving the social dilemmas encountered daily by each citizen within their community’s civil life that occurs when caring relationships dominate the community’s networks of citizens, especially the neighborhood network of each citizen’s family. There are many studies that a community with a high level of social capital recovers more rapidly after a disaster than a community with a lower level of social capital. It comes to mind today as I listen to the evolving disaster in Florida from the Irma hurricane.
    As a final observation about cognitive dissonance, I wonder if part our our nation’s quality and cost problems related to its health care, are really NOT controllable by its healthcare industry. Is it possible that the social determinants of poor health are really not resolvable by Primary Healthcare or a high-tech Emergency Department? As a measure of this, I have studied three data sets, 1982-1996 and 2001-2006 and 2005-2014 for State by State maternal mortality. There is a high Pearson correlation coefficient that exists between a State’s poverty level and its maternal mortality level. It is not an absolute relationship but high enough to be important.
    To solve our level of cognitive dissonance within healthcare reform, we will need to more clearly understand the humanitarian realms of knowledge in conjunction with its scientific realms of knowledge. Warmth, acceptance, honesty and empathy expressed over-time are the basis of trust. Social dilemmas become resolvable with the expression of trust, collaboration and reciprocity. Managing a Commons, aka national health spending, will not occur successfully without an increase in our nation’s level of social capital. This will require a community by community process that is nationally promoted by a new semi-autonomous instituted by Congress with NO relationship to the distribution of economic capital. I am suggesting a Cooperative Extension Service for healthcare.