Medical Practice

Doctor-Patient Relationships: I Don’t Babysit – I Want to Empower

By HANS DUVEFELT

I have known doctors that cultivated a dependence among their patients by suggesting their health and safety depended on regularly scheduled visits and laboratory testing for what seemed to me stable, chronic conditions. People would come in every three months, year after year, to review cholesterol numbers, potassium levels and glucose or blood pressure logs and have a more or less complete physical exam every time. Patients would also get scheduled for rechecks of ear infections and other simple conditions I always thought patients can assess themselves.

Compare the effort on the part of the physician with that type of practice versus seeing stable patients less often, doing more urgent care, and being more available for new patients. The first approach seems comfortable, possibly complacent, and the second more demanding, but also more satisfying, at least to me. My goal is always to make my patients as independent and self sufficient as they can be. I don’t want them to be dependent on me in an unhealthy way.

It is a matter of temperament, but it is also a matter of stewardship and resource management if we see ourselves as serving the populations and communities around us.

Maybe it is because of my Swedish upbringing and education, but I would feel guilty if sick patients or even relatively healthy people don’t even have access to a personal physician if I were to spend my days over-monitoring stable conditions.

In this medically underserved state, don’t we have a responsibility to consider whether we are getting too comfortable in our chronic care routines? Patients check their own blood pressures and glucose levels. They could get in touch if their numbers worsen. Do we really need to bring them in to make sure they don’t stray when there are people in our communities without access to care?

I sometimes actually use the phrase “I don’t babysit”. I don’t necessarily use the word “empower”, but that is what I always try to do with my patients.

I admit that it doesn’t always work when I ask a patient to let me know if their home blood pressure drifts above 140 or their weight goes up by 5 lbs. But this is where I think we all, providers, clinics and healthcare organizations, can utilize support staff. Someone other than the physician could reach out to patients for followup information instead of hauling them in just to establish they’re on track. We obviously need to do that with complex or very ill patients, but it is inefficient and sometimes unhealthy to do that with every patient taking medications for relatively benign conditions.

It is easy to feel responsible for our patients if our prescriptions cause harm or even carry great risk, but this is (still) a (mostly) free country and every patient has choices to make every day that we have no control over. We can’t be there, watching their every move. We know people don’t always take their medications or follow our advice. We might make them more compliant by seeing them more and more often or by instilling fear in them or insisting they let us assume all responsibility for their disease.

But that amounts to an unhealthy doctor-patient relationship, undeserving of a civilized and free society.

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

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  1. What you say all makes perfect sense to me, especially for relatively well educated patients willing to take an active role in their own care management. However, I’ve heard way too many doctors tell me that their number one priority is to stay out of court and doing more testing and face to face interaction rather than less helps them do that. I don’t think the fear of litigation is nearly as great in other countries including those in Western Europe, Canada, and, especially, Asia. From a cost standpoint, the good news is that primary care accounts for a relatively small part of overall healthcare costs even within the physician and clinical services subset of care. The adequacy of the supply of doctors, particularly in rural areas, is a separate issue though I wonder if NP’s and PA’s can provide “good enough” care for stable patients who can help manage their own care.

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