Monday, January 23, 2006

Patient v. Doctor: Two Men Enter, One Man Leave


This the word I hear most often from physicians to describe the patient-physician relationship. Simply put, it means involving antagonistic parties or interests. The fundamental element of the modern day healthcare system was and continues to be established on this relationship and yet this word has crept into our lexicon as a way to best describe it. Clinics, exam rooms, emergency departments, operating rooms, intensive care units and the wards are our initial fields of engagement. In so doing we approach each encounter as a mini "Thunderdome". The patient and their doctor enter into an encounter and one is expected to win and the other to lose. The crowd roars in unison, "Two men enter, one man leave". Despite major advances across all disciplines in medicine physicians are no longer trusted to assure safe and effective care.

Patient advocacy, it is perceived, is secured, not from the compassion of the physician, but from the sword of the attorney.

If physicians continue to see patients as potential adversaries the essence of the relationship is destroyed. It's too easy to say, "but they started it". All relationships are a two way street. Both sides played a role in this massive arms build-up and both sides must be involved in its eventual resolution. So is it time to part ways? Or as Stephen R. Covey suggests, if we can't reach a win-win deal then it may be time for no deal. Our instincts for potential adversaries is so highly tuned it is almost impossible to meet a person, think of them as an adversary, and not communicate that to them in some way through our style of interaction. Is this the message patients and physicians are silently communicating to one another?

Something changed.

Throughout much of modern history the patient-physician relationship has been a central feature of the current healthcare system paradigm. It was based on trust. There was a value for value exchange. Using a combination of their intellect, training, skills and experience physicians provided the means, as best they could, for patients to overcome or at least manage their illness or injury. In return patients provided, as best they could, payment in the form of money, esteem, status or a sense of achievement and contribution on the part of the physician. For centuries this model worked well, both parties benefited. It was a win-win deal. Over the latter half of the 20th century it slowly became a win-lose deal characterized by an adversarial environment. The trust is broken on both sides. Physicians are expected to act like Marcus Welby, MD but more frequently find themselves preparing for a potential complaint or lawsuit before the encounter occurs.

Pistols at Twenty Paces

If an encounter results in a complaint, claim or lawsuit we manage to turn it into a modern day duel. In the old days after an insult to one's honor a duel was considered a "respectable and acceptable manner to resolve disputes". After an offence occurred, "whether real or imagined, the offended party would demand 'satisfaction' from the offender". The physician, I mean offender, then had three choices.

1) Public apology
2) Restitution
3) Choosing weapons for the duel

Choices number one or two were non-violent means of resolving disputes. Choice number three was an entirely different matter. The winner of a duel was considered a hero and was accorded increased social status. Failure to show up to fight in a duel was considered an act of cowardice. Honor meant something then and I think it still does today. Dueling was outlawed years ago and the primary method of resolving disputes is though our legal system. We still expect a winner and hero to emerge from these disputes. The problem is when we allow ourselves to relate to people as potential adversaries we set ourselves up for the inevitable showdown. We are seeing the gauntlet thrown down before doctor and patient meet. Many in the medical profession feel the problem is physicians are not communicating well enough with patients when it may be that they are reading us loud and clear. We consider them future adversaries. Patients are also accused of not being very good at communication. I suspect that is equally misunderstood as well. Physicians are reading them loud and clear. They don't trust us and unfortunately the patient-physician relationship depends on trust. What is more concerning is that the current paradigm of healthcare depends on the patient-physician relationship.

Circle the Wagons

The patient-physician relationship is what I believe is under attack. It is the cornerstone of the established paradigm for our healthcare system. It is exactly where a truly challenging and emerging paradigm must strike in order to become established. If that is the case then the patient-physician relationship is undergoing a fundamental transformation. Whatever form it takes must conserve the essential elements of the relationship. It depends on the patient's trust in the intellect, training, skills and experience of the source providing the healthcare service. A new paradigm for healthcare will continue to provide these services but its form will be different, radically different. The source of the services provided may be at the heart of what will appear radically different.

Essential Elements for a New Healthcare System

1) Be easily accessible
2) Always maintain the highest standards of care
3) Cost a fraction of the current healthcare system
4) Support transparent and accessible quality of care standards on all healthcare entities
5) Maintain a universal health care record
6) Produce outcomes that far surpass current best standards
7) Resolve disputes in a win-win manner
8) Transformed source of healthcare services

Oh Yea, One Last Thing

There is one other thing that I predict about the form of a truly new paradigm for delivering healthcare. It will most likely involve a markedly diminished role for both physicians and attorneys. Sorry but that is just how I feel about it. The essential element, and therefore the most conserved part of the current healthcare system, is that it was created primarily for patients, not for physicians and attorneys. It may be in order for our Healthcare System to survive it will need to jettison unessential baggage and personnel. If physicians and attorneys continue to consume time, energy and resources in these ugly battles in Bartertown it will ultimately be the patient who walks out of Thunderdome the survivor.

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