Where is Relationship, Authority, and Trust in Health Care Today?


Healthcare is on a different trajectory from most other businesses today. It’s a little hard to understand why.

In business, mass market products and services have always competed on price or perceived quality. Think Walmart or Mercedes-Benz, even the Model T Ford. But the real money and the real excitement in business is moving away from price and measurable cookie cutter quality to the intangibles of authority, influence and trust. This, in a way, is a move back in time to preindustrial values.

In primary care, unbeknownst to many pundits and administrators and unthinkable for most of the health tech industry, price and quality are not really even realistic considerations. In fact, they are largely unknown and unknowable.

The real price in primary care isn’t just the cost of each doctor visit. It is the cost of the total number of visits needed to solve a problem, and also the cost of the various tests, procedures and treatments each primary care doctor orders when solving that problem or managing a particular condition. This can vary enormously.

In Accountable Care Organizations, actual costs are compared to presumed or projected costs, which are based on Hierarchical Code Categories (see my post), which aren’t well known or commonly used by primary care doctors. To a degree, you can game this baseline cost calculation by mastering HCCs (Medicare Advantage plans’ financial well being hinges on making the most of this; this is why they offer doctors $150 to sign off on a list of each patient’s known or suspected expensive diagnoses).

Quality in healthcare is largely in the eye of the beholder. I’ve said it before and I’ll say it again here: A patient population’s immunization rates or aspirin use or non-use (depending on shifts in knowledge) are not comprehensive measures of quality. Accuracy of diagnosis, if anything, is. But who is measuring that? You might say “those who can’t practice medicine measure it”. That’s why most quality measures these days are of things you don’t need a medical degree or license to accomplish.

Primary care, in the eyes of our patients, is instead about relationship, authority, trust and (gasp) convenience. This is what people in most other businesses talk about all the time. It is what even tech and medicine pundits, EMR companies and many other middlemen want for themselves. They don’t want to be evaluated on the basis of price or quality standards set by others. Yet they want mass market medicine for the masses, not relationship based care.

Driving 200 miles between my two clinics, I often listen to audiobooks. Once I finished my Board Review, I turned to business books. “Influence”, “Authority”, “Brand”, “Story” and “Content” have replaced “Quality”, “Six Sigma” and “Excellence”. In business now, it is all about standing out and setting your own standards. It is about building relationships with and listening to consumers.

In healthcare, I see the paradox that insurers are now reaching out to patients to check up on them while at the same time making doctors work so hard and so fast producing “encounters” that there is less and less time for us to talk with our patients when we are with them, and never mind on the phone in between visits. Do they really think patients wouldn’t rather see their own doctors having enough breathing room to talk to them than have some strangers from out of state they never met calling to check in?

We have data that the doctor-patient relationship influences outcomes. From hospitalization rates to prescription adherence to effectiveness of treatments for mental health diagnoses, it is well known that the doctor is a large part of the treatment.

Doctors have increasingly become part of multicenter systems that, in spite of efforts like Patient Centered Medical Home recognition, simply have become too large and impersonal to foster the kind of customer relationships the business world is now realizing are necessary.

Between the bottom-line objectives of such healthcare organizations and the bureaucracies of health insurers, doctors and patients are clearly not in complete charge of their own relationships anymore.

So what happens with those relationship dependent outcomes when so many doctors feel like lineworkers, rather than professionals? What happens to their ability to nurture those relationships, gain that authority and earn that trust?

What happens if they lose it altogether?

There are modern, big companies who listen to their customers, even research and anticipate their customers’ needs. There are companies that empower their employees to solve customer problems, give refunds and do extras. There are companies who treat employees like owners or even offer them actual ownership.

Healthcare could do some more of that.

But there is more, lest we forget: Doctors aren’t just employees.

Who has the license to practice medicine? Who places the needle or scalpel? Who selects the medication? Who says “I’m sorry, we did everything we could” or “Congratulations, it’s a beautiful baby girl”?

Salespeople, YouTube stars and business leaders give a lot of thought to their customer relationships, their personal authority and the essentials of building and maintaining trust.

Are we doctors doing enough of that? Those things are ours to claim, and to strive for. Even if a big corporation issues our paycheck.

Hans Duvefelt is a Swedish-born rural Family Physician in Maine. This post originally appeared on his blog, A Country Doctor Writes, here

8 replies »

  1. Almost everything you do as a physician can be done better by someone else EXCEPT arrive a DIAGNOSIS. It is a uniquely iterative process for testing various Hypothesis using inductive and deductive reasoning involving various sequentially-linked intervals of time. It evolves during a physician’s professional career to evolve one’s own collection of pattern recognition tools. Whether or not these tools can or should be revised by new information is the essential dilemma face by each physician.

    I join my colleagues in tipping my hat to Hans.

  2. Good, Hans. Thank you.

    If we scrutinize all the things docs do, it seems that arriving at a truthful and accurate diagnosis is our singular comparative advantage. No one else is trained to do this as well as the physician.

    Happily, the new molecular biology technology is bringing forth countless new diagnostic entities and disorders and diseases….serving us a cornucopia of differential diagnoses to think about and diagnose if needed.

    Stay as sharp as possible.

    Less well-trained people trying to do our jobs will get litigated away. There is no substitute for good rational thinking. World class healthcare and medicine is an intellectual pursuit.

  3. I sure would like to know who reads those surveys. If it’s the survey company and they just score the results so that more LIKES mean nothing needs to change, then it’s useless and means my opinion stands for nothing unless it’s hidden the herd’s opinion.

    The best teacher I had was ornery, unlikeable, and challenging. He made everyone think for themselves and made us think outside the herd. His classes were tough, interesting and I bet if there was a survey, he would have been fired.

    Show me a primary care genius (not found one yet) and I’ll put up with a lot to see them – even uncomfortable waiting room chairs and an hour wait.

  4. I just read a piece that stated that if you don’t establish trust, your skills are irrelevant.

  5. Amen, Medicine is about diagnosis and treatment, everything else is moot if either one is incorrect.

  6. We can no longer talk about our “next door neighbor” network because NEXT DOOR is a proprietary name for an internet social network. The only term applicable might be a Micro-Neighborhood Network. Somehow, I have trouble thinking of my neighbors that I encounter almost daily as a Micro-Neighborhood. It would probably be ok for an advertising executive and their CEO clients but not for me. The layers of governance between the C-Suite folks and the front-line of an institution now range from 10-15 as opposed to 3-5. The issue of course is that the decision rules applicable at each level of an institution’s governance creates a drift without a meaningful connection with an original intent or purpose.

    This all began to become entrenched within the healthcare industry when the last dangerous epidemic virus was controlled: measles. The first measles vaccine was licensed in 1963. These epidemics peaked about every 6-7 years, the last peaking in @1965. Other than outbreaks imported by foreign travel and occurring as a result of children who weren’t immunized, there have been no large epidemics of measles since 1969. Many children either died (@ 600 annually), became deaf, or lost cerebral function. It was a terrible illness. The institutional structures that led to this accomplishment have subsequently led to co-dependent connections throughout the economic structure of healthcare. Corporate “social responsibility” within institutional governance is now a lost art. Personal income is the dominant measure of professional development as expressed by 15 minute outpatient appointment schedules. We are left to agonize about our commitment to Trust, Cooperation and Reciprocity as a therapeutic tool in the face of the institutional co-dependency that surrounds the serenity of each physician.

  7. I view myself as both a patient and a customer. For better or worse, most people evaluate doctors, especially primary care doctors, on the three A’s — affability (personal chemistry and bedside manner), availability (how quickly can I get an appointment) and last and least, ability (diagnostic and communication skills).

    Ability, including communication skills and a strong referral network, would be my highest priority but personal chemistry and availability are also important. Even if I can get an appointment quickly, if I find that I always have to wait an hour in the waiting room before being called in, I would view that negatively because it suggests that the doctor grossly overbooks and apparently has little or no respect for the value of my time or any other patient’s time for that matter.

    If I needed something sophisticated like a surgical procedure, I think it was Steve2 who told me that I shouldn’t want someone who is brilliant at surgery but an arrogant jerk because the nurses may be afraid to call him in the middle of the night if there are complications.

    The bottom line is that both a patient mentality and a customer mentality are important in choosing a doctor, in my opinion. That said, I don’t put a lot of stock in surveys either but would pay more attention to reviews if the reviewers spell out their likes and dislikes.

  8. I hate surveys – they usually have nothing to do with the care (actual medical care) you received. They’re there to lead the patient to a pleasant conclusion and send their friends in for treatment.
    How long did you wait to see the doctor?, Did the receptionist smile at you?, Were our chairs comfortable? How was the waiting room temperature? Did you enjoy your visit?.

    I can’t remember the number of times I’ve been misdiagnosed. I’m at the doc’s office to get an accurate diagnosis and intelligent care to solve the problem. I’m not there to be pampered with useless, hypnotic and inane questions. I’m not a customer – I’m a patient.