August 22, 2013

Is the Doctor-Patient Trust On Life Support?

The answer is not a straightforward yes or no, but is dependent on where you live, your current age and whether you have good insurance. Yes, Medicare is considered insurance, but some doctors are no longer accepting patients on Medicare. And here I am not including doctors that are operating on contract medicine. In largely rural areas, often the patient must travel long distances to see a primary care physician or even further to see a specialist.

If you live in a doctor dense area, then you have an easier task of finding a doctor that may be the right fit for you. Under the law changes happening because of the Affordable Care Act, the next couple of years may be difficult for some patients. As the changes take place, some patients may become dissatisfied with the doctors they are required to see, as it appears there will be a team approach once you become a more complex patient with two chronic illnesses or diseases. Once you are on Medicare, this may become even more problematic.

No one can say with certainty how we will be affected by the physician shortage or where the physician shortage will be in relation to the population most needing physicians. Many physicians are leaving private or small practices for employment with hospitals. Other physicians are leaving smaller towns for larger cities and larger practices. A few are setting up small practices in larger communities.

Dr. Shirie Leng has a blog about the doctor-patient relationship and why the trust is waning in this relationship. While she does not become severe about patients, I may be reading between the lines, but I do come away with the feeling that she feels many patients would be better off putting more trust in their doctors.

Her statement here is very much on target. “Trust has many components. It is based partly on compatible communication styles. The Journal of General Internal Medicine points to the patient’s assessment of the physician’s communication, level of interpersonal treatment, and knowledge of the patient. In these times of short visits, short-tempered doctors and patients, and fragmented treatment, all those factors are in jeopardy. Patient dissatisfaction implies poor trust. Race and gender of both patient and doctor has an impact. Patients who genuinely like their doctors tend to trust them more.”

Dr. Leng does balance the scale when she uses information to put her own profession in a poor light when she talks about the paternalistic approach to medicine. Does she mean that female doctors are better? I had to ask this question as I have seen both sides of this issue and the bad female doctors are often worse that male doctors in similar situations. Yet on balance, more female doctors empathize with their patients than male doctors ever have.

In the 1950's, it was thought that physician trust was based on doctors treating everyone equally. Today the media has promoted this as not true and that there are other reasons to be concerned, such as regional differences in the standard of care.  A number of stories are used for breaking this thought. Doctors that over-prescribe, take money from drug companies, and turn down Medicaid patients are just a few of the things the media makes sure we are aware of.

All the data is soft and outdated in the research on doctor-patient trust. Current discussions suggest doctors are losing ground on this issue. The following things might help a little: (I will quote Dr. Leng's ideas, as they are relevant.)
1. “Doctors cannot take money from drug companies. Ever. Not even a pen. Just don’t do it.
2. Practice good communication, or learn how if you don’t know. This goes on both sides. If you don’t understand, ask. If you are the patient, bug the doctor until you are satisfied. If you are the doctor, ask and answer for as long as it takes.
3. Take money out of the conversation. Universal health care is the only way to do this successfully.
4. There is nothing wrong with finding a doctor who is the same gender or ethnicity as you.
5. Understand that nobody has all the answers. Doctors don’t know everything, patients don’t always know what they want, and none of us like this fact. We like to think medicine is an exact science but it is not.
6. Doctors must keep up with the latest real research. We must go to our annual conferences. Where I work, the only people who get to go to the annual conference are the people who are presenting, who are the researchers, who always go, and who do less clinical work. No. Everyone goes. Close the ORs. Close your office. Can’t afford to close your office? Use the databases like UpToDate, which has a hundred doctors employed solely for the purpose of gathering the latest clinical info.
7. Tort reform. All the research and conferences in the world don’t do anything if people are afraid to follow what the research says.
8. Patients cannot expect miracles. Those days are over. Patients cannot expect that they can get every test and treatment known to man. Those days are over too.
9. Let’s all recognize our humanity.”

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