You probably want your doctor to care about people, but how much do you want her to care about all of them? That’s the question I ask when I read articles – generally by bioethicists, often respectable ones – asserting that one of the moral responsibilities of physicians is to be responsible stewards of the healthcare dollar.
This rhetoric concerns me, because I worry it may ultimately degrade the already-challenged physician-patient relationship.
The cornerstone of medicine, the most fundamental principle, in my mind, is the absolute, rock-solid belief that your doctor is your unqualified advocate and will work as hard as possible to provide you with the best medical treatment possible, as if you were a member of her own family (Dr. Marty Samuels and I originally described this as “The Uncle Marvin Test”).
To be clear: this doesn’t mean the most expensive pills – by all means prescribe or substitute an equivalent generic, when available. This doesn’t mean the most expensive diagnostic studies – it’s generally in the patient’s medical interest to avoid unnecessary procedures that usually carry some intrinsic risk and also can lead to false positive results that can in turn lead to needless anxiety — and on occasion, permanent harm. This doesn’t mean extra days in the hospital – a hospital is one of the world’s most dangerous places, and it’s often in a patient’s best interest to be discharged as soon as possible (see here if you need more convincing).
It’s a simple idea – show patients the notes that doctors write about them– but it’s also a dangerous idea … in the best sense of the word. It’s dangerous because the very idea forces a conversation and in the course of that conversation, some uncomfortable tensions surface. Jan Walker and Tom Delbanco, co-directors of OpenNotes, a project supported by the Robert Wood Johnson Foundation’s Pioneer Portfolio that enables patients to see their doctors’ notes via secure e-mail after a visit, published a preliminary set of results from their first study. Actually, it’s just a pre-study: they surveyed doctors and patients about their expectations of how the OpenNotes idea would play out. And what they found is fascinating – and uncomfortable.
Doctors and patients are clearly divided about the expected benefits and consequences of the OpenNotes intervention. On a wide range of possible benefits, ranging from a greater sense of control to increased medication adherence, doctors are more skeptical than patients. But what really jumps out are the responses to questions of whether patients would find the notes more confusing than useful, and whether the notes would make them worry more. The gap is dramatic. In each case, most doctors said “yes” while less than one in six patients agreed. Ouch. That’s a big gap and my sense is that we should be talking about what it means. From my perspective, it appears that many doctors are underestimating their patients and that this underestimation could lead to less patient engagement and ultimately poorer care. Call it a hunch.
The idea that physicians are going to be far less important in the medicine of the future seems to be a central assumption of many next-generation health companies, an assertion that, like undergraduate Shakespeare productions set in the present day, may once have felt daring and original, but now seems merely tedious.
The logic goes something like is: Patients are accustomed to seeking insight from their doctors but doctors are far less good at providing this advice than most patients realize. As more consumer-based tools for managing health become available, patients will recognize that they now have the means and the motivation to take care of their health better than their physicians, and medical care will move directly into their hands.
Arguably, a form of this already happens today, as patients make extensive use of non-prescription products (e.g. the Vitamin Shoppe reported net sales of $750 million in fiscal year 2010), non-traditional practitioners (e.g. total revenue received by chiropractors is estimated by Hoovers to be about $10 billion), and seek medical advice from friends on Facebook (which may have directly saved at least one life).
What these data don’t convey, however, is something I’ve had the privilege to experience first-hand: Doctors enjoy an exceptionally durable bond with patients — especially those patients with chronic illnesses. The level of trust reported by patients for their physicians is remarkable, and the role of physician as trusted adviser is difficult to overstate. It’s a huge burden to manage disease on one’s own, and it’s generally reassuring to know your physician is with you at every step — something I believe still happens, by the way, although obviously not in every case.
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.