Preserving the Patient-Physician Relationship

A recent commentary (J Noseworthy. NEJM 2019; 2265-9) discussed the need to preserve the patient-physician relationship.  The author, who previously led the Mayo Clinic, makes a number of useful points.  Though, at the outset it is important to recognize that the care at the Mayo clinic is not representative of the care elsewhere.  In this institution, there is a selection bias both of patients and physicians.  Based on my knowledge of patients evaluated there (a small sample), patients are much more likely to undergo extensive evaluations.

Key points:

  • “Physicians in the United States are increasingly caught between the conflicting concepts of medicine as a humanitarian profession and health care as a competitive business.”
  • “Medicine’s most fundamental element remains the relationship between patient and physician…I believe it must remain central to medical practice even as medicine evolves.”
  • Principles include the following:
    • spending adequate time -to deal with uncertainty, treatment plans that are failing, and comfort those at the end of life
    • support the work of a coordinating physician -to address comprehensive care for patients with complex health issues

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“Mistrust in Science –A Threat to the Patient-Physician Relationship”

A recent commentary, “Mistrust in Science –A Threat to the Patient-Physician Relationship” (RJ Baron, AJ Berinsky. NEJM 2019; 381: 182-5), addresses the deterioration of trust in the patient-physician relationship and potential ways to improve this.

Shortly before reading this, I read a newspaper article titled “Newtown Parents Fight Back” in Sunday’s AJC (related article online: Newton Parents Score a Win…). In this article, some of the parents of the 20 children who were killed in Newton, Connecticut have brought successful lawsuits against ‘hoaxers’ who claimed that the “rampage had been staged, with crisis actors.” Some of the parents have received death threats subsequently.

In this ‘misinformation’ age, it would be naive to expect that medicine and science would be spared. The alluded commentary makes the following points:

  • “Clinicians enter patient encounters with the reasonable presumption that they will be trusted. After all, they have powerful knowledge and good intentions…But, medicine is changing.”
  • “The legitimacy of the medical community rests on the the credibility of medical science…Physicians rely on that foundation in every interaction they have with their patients.” And on “the intimate and personal nature of each individual doctor-patient relationship”
  • “Medical practice is becoming increasingly corporate…In 2016, for the first time, less than half of practicing physicians owned their own practice…Less attention has been paid to how corporatization changes patients’ experience and …trust.”
  • “Gallup polling has revealed that confidence in almost all institutions in the United States…has deteriorated greatly…confidence in the medical system fell from 80% in 1975 to 37% in 2015.”
  • “Alternative sources of ‘authority’ have emerged to fill gap” including social media platforms, friends and relatives.

“Given the decline in trust in the institution of medicine, simply asserting medical authority or citing evidence is unlikely to win adherents…Skepticism…is a widespread phenomenon…appealing to a neutral or independent ‘referee’ of the truth…on a given subject–does not actually change minds…attempts by experts to correct misinformation may further entrench erroneous beliefs.”

Pathways to Trust

  • “Feeling recognized is a precondition for trust.”  Having to repeat stories over and over again can be ‘trust-destroying’ as the individual feels as a stranger in the health care system
  • “Explicitly acknowledging the role…of other members of the health care team may be another way…Speak positively about the staff [and colleagues]…This practice …increased patients’ trust and satisfaction.”

My take: The authors note that in this age, science s devalued and relationships are more influential.  Thus, creating trust goes back to Peabody’s 1927 admonition: “The secret of the care of the patient is in caring for the patient.”

In the newspaper article, a book publisher involved in the promoting the Sandy Hook conspiracy had to meet one of the parents as part of a lawsuit.  “At the end of the day, Gahary shook Pozner’s hand and apologized. He offered condolences for Noah’s death.”  As in medicine, getting to know each other is the surest way to garner trust.

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