The Forgotten Value of Patient Relationships

May 26, 2025

I often write here on the importance of the physician-patient relationship and how corporate medicine has deliberately suppressed primary care physicians by removing their hospital privileges and replacing their hospital care of their patients with the newly created position of hospitalist. The hospitalist is one more reason hospital care of primary care physicians is fragmented. Dr. Brad Rosen says:

“Hospitalist medicine has a lot of hand-offs, and with every hand-off, there is the risk of ‘voltage drop’ of critical information — just like the kids’ game of telephone.”

In this article I can find no mention, even once, of the three magic words, “patient-provider relationships,” which have been on the chopping block in medical care for decades. When I began practicing, relationships between patients and providers were very important, as were relationships with nurses, other doctors, and everybody else in healthcare. For those people who don’t know about the value of patient-provider relationships and probably never will know, I am here to tell you that patient-provider relationships are the most important part of medical care. I certainly mourn their passing, but I’m probably one of the few who do because young providers can’t mourn things they've never known. As time has passed, nothing has been done to preserve patient-provider relationships and much has been done to destroy this critical part of healthcare.

Recently, sitting beside me as I waited in the doctor's office, was a patient I met for the first time seven years ago. Seven years ago, as part of my examination of him without his shirt on (something that can’t be done on telemedicine or by AI), I could see an odd but angry looking, reddish skin tag on his right shoulder. At that time, he told me he had had a biopsy a few yeas previously, but never heard the results. I remember my conversation with him, my exam, and removing that angry looking skin tag completely and sending it to the pathologist. I remember the day that the test returned indicating melanoma. I remember the discussion I had with this patient. I remember referring him to the dermatologist who referred him to a plastic surgeon who did a wide local excision, which later came apart and resulted in many more visits to me, until the incision finally healed.

In the meantime, my then patient was the subject of many meetings with many other doctors and ultimately, he was told he needed intensive chemotherapy and that he had two years to live if he didn’t get the chemotherapy. He decided not to get the chemotherapy and seven years later he was sitting next to me in the waiting room, still alive and well...not just living and surviving. He told me he remains asymptomatic and cancer free at this time. I also remember that he has no children and that his wife died several years ago of a heart attack. I remember that he works as an orderly in a long-term care center and that he likes his work and he likes his patients and he values the relationships he has with his patients, spending time with them, getting to know them, and having a fun day. The hospitalist never knows this kind of information for patients and the care of the hospitalist is the poorer for the lack of this knowledge about patients.

I want to talk a little bit about melanoma. We commonly think that melanomas are mostly black with irregular borders and irregular shades of black and brown. Although this melanoma was in a place of high exposure to ultraviolet light on his right shoulder, it wasn’t black, but I biopsied it because it looked angry, and because my judgment said it was probably not benign. And here is where the primary care relationship and the patient-provider relationship begins to work its magic. There are a lot of services today such as emergency rooms and walk-in clinics where people go through the paperwork. In other words, providers would see a patient, talk with the patient, write a note, and be done. For many years no one bothered to notice this patient's skin tag. It was not new and it could’ve been biopsied many times in the several years he had been keeping his provider appointments.

As a primary care provider who is interested in establishing long-lasting patient-provider relationships, I decided to biopsy this patient's skin tag. I could’ve let it go completely as others had. I could’ve sent him to a dermatologist in which case he would’ve been seen in 6 to 9 months and the melanoma might have grown and become metastatic. What I find offensive about the article promoting the care of hospitalists is the concern only about information transfer. Today in the healthcare world, charting reigns supreme. Indeed, the chart becomes the real patient. The chart provides all sorts of interlopers and entrepreneurs access to tons of personal information that they can use to critique a practice from afar in order to criticize the care or delay or deny payment.

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In a world where most providers seem to be content with the sterile exchange of information, where the chart becomes the patient, where telemedicine is seen as a good option, and AI can make the “best diagnoses,” I would say that direct primary care is really a good option for patients. This is the consumer’s opportunity to have a relationship with a provider, somebody who wants to care about the patient as well as the outcome. In direct primary care, the provider needs approximately 600 patients in a practice. This is a much smaller number of patients than the provider would be seeing in the average clinic. The point is that the patients pay a monthly fee somewhat like an insurance premium. In return for their payment, they get free clinic visits and 24/7 phone access to the physician, and generally labs and prescriptions at cost or near cost.

So, what’s the problem with direct primary care? Direct primary care sets the clock back to a time when healthcare made some sense, when providers and the patients had good, long-lasting relationships, when the outcome was a satisfied customer. Just ask average consumers how satisfied they are with healthcare today.

If you don’t think that insurance companies are greedy and self-absorbed, you have another think coming. They see themselves losing a lot of money on direct primary care. The health insurance companies are loaded with pork. As senator John Kennedy says, “pigs squeal when fat is cut.” In this case, these pigs squeal all the way to our state and federal legislative bodies, crying that doctors aren’t licensed to function like insurance companies. Of course, insurance companies can be doctors and worse yet; they can completely negate your doctor and your doctor’s good care. And even worse yet, the courts side against the consumer and in favor of the insurance companies. Again, money talks.

Since it is against the law for insurance companies to practice medicine, they easily circumvent the law and its meaning by employing doctors who get paid for reviewing insurance claims. The more claims these doctors deny, the more they get paid. To my mind, these insurance company doctors are highly paid prostitutes.

Fragmentation of medical care is the direct result of losing the patient- provider relationship. The hospitalist is a primary example of fragmentation because they might be on for a day or a week and be gone. I have written and talked about fragmentation of medical care for decades. The damage done to patients and the financial cost are neither measured nor measurable. When I began my medical training 52 years ago, we were trained to actually care about what happened to the patient after they left our offices or the hospital. As a third years medical student, we were trained to do what was called a discharge summary, not just a discharge plan. The discharge summary is a much larger concept, and a much more useful document than a computer-generated discharge plan.

To begin with, we were required to provide information to help the patient, the present providers, and the referring doctors know not only what was found and done, but also what was anticipated in the post-hospital or post-clinic visit. As third-year students, the discharge summary was really the beginning of how to think more than what to think. The discharge summary was a valuable document helping everybody, including the patient, the attending doctors and students, and of course the referring doctor as well. In residency, we had rotations, so a good discharge summary was very important for the next doctors who would be on that rotation and taking care of that patient when the present provider had moved on to another rotation. One more point. All of this information had to be on one page. The idea was that no physician would turn to the second page, so whatever we had to say had to go on one page. That taught us to do a concise, succinct, complete, and pleasant summary. When doctors sent a patient to me, I always responded with a letter thanking them, giving them a follow-up on the patient's care, and making plans for future care.

The discharge summary was incredibly important for patient care, and we knew it. The Centers for Medicare and Medicaid Services (CMS) didn’t need to explain its value nor did CMS need to threaten us to get us to do what we were supposed to do. The CMS draconian system of punishment is decidedly ineffective.

In those days an obstetrician/gynecologist could do primary, secondary and tertiary care. I chose to emphasize primary care, so I had 10,000 patients who called me their doctor. When they were hospitalized, I was still their doctor. When they had surgery, I did it. And when they went home, I was once again still their long-time clinic doctor. These patient-provider relationships were important and long lasting. There was much to be said for preventive care and maintenance in those long-lasting relationships. I personally find the idea of hospitalists, case managers, and fragmented care not only foreign to me, but decidely distasteful.

First, with hospitalized patients, if they had primary care physicians, somebody should actually pick up the phone and call the primary care doctor and inform the doctor that the patient was in the hospital.

Second, preventing primary care physicians from having privileges at a hospital and substituting hospitalist care for primary care is an excellent way to steal patients. Large organizations want to do this and are able to do so with impunity even though physicians can be punished severely by state medical boards just for being accused of stealing a patient. As the old adage goes, might makes right. Third, the hospital CEO can control the hospitalist much better than they can control a doctor in private practice.

Fourth, the hospitalist has no real investment in patients seen. When hospitalists go home, they don’t worry about the care of the patients in the hospital because somebody else is now in charge, writing orders, writing notes, and taking care of the chart. So, it looks like the patient is getting care but instead, the chart is getting care. The point is that there is no real relationship between the hospitalist and the patient, at least not the kind of relationship that grows from years of caring for generations of a family. There is no long-term ongoing or continuing relationship with the patient. So that’s the advantage for the hospitalist in this relationship. There is obviously no advantage for the patient unless you call taking care of the patient chart an advantage. If you ask a hospitalized patient who their doctor is, they will generally say, “I don’t know,” because in this situation they have no way of knowing who is their doctor.

A few days ago, I had the opportunity to talk to a so-called case manager on behalf of a friend for whom I have medical power of attorney. I tried to find out who my friend's doctor was, and she said, “I don’t know. They’re on for a week and then gone.” So, exactly who is responsible for my friend's care? Who is concerned for the success of the plan when my friend goes home? Who can my friend call for emergency? And who will follow my friend in the clinic and what will they know and how responsible will they feel for my friend's outcome? In my opinion, the idea of the hospitalist works well for everybody except for the patient.

Rural Doc Alan

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