The Sanctity of the Patient-Physician Relationship

Medical care is always best when the patient-doctor relationship is maintained and secure. In the last 50 years, it has never been at more risk than it is today, and that relationship is rapidly decaying. Fifty-five years ago, I decided to train for a career that I would love. Now retired, I can still say I not only have loved my medical career, but I continue to love it.

Residency at that time was for the most part 36 hours on and 12 hours off. Pay was $10,000 a year which after taxes turned out to be about $750 a month, half of which went to rent.

In those days, taking care of patients was actually fun. Yes, there were rules to follow, but if you followed them, you could pretty well stay out of trouble.

I recently read an article by Dr. Edwin Leap who talked about young doctors who’d been in the business for only two or three years who were looking to transfer out of actual caring for patients and trying to do something less patient oriented, to my mind an odd way to conclude your 12 or 16 years of grueling medical training.

Dr. Pierre Kory recently wrote about losing the sanctity of the patient-doctor, or patient-provider relationship:

Gone are the days where doctors could rely upon observation, intuition, clinical experience, physiologic reasoning, knowledge of pharmacologic mechanisms of actions, the pitting of safety of the medicine vs severity of illness of the patient, patterns of recognition, and assessment of risks/benefits/alternatives as a patient falls ill in our care (as we have for centuries/millennia).

Dr. Hans Duvefelt writes often of the magic of the family physician, repeatedly emphasizing the importance of the patient-physician relationship.

I recently wrote about two women with ectopic pregnancies were refused treatment by the doctors in a hospital. I am neither so stupid nor depraved that I think that refusing to treat ectopic pregnancies is appropriate, reasonable, or good care, but I don't think government belligerence is going to solve the problem.

The usual government reaction to fixing healthcare problems is belligerence. And if a little belligerence doesn’t doesn’t work, up the ante with more belligerence. The real problem here is that all this does is threaten doctors. They are worried about losing their licenses. They are worried about being reported by their peers, nurses, or CEOs to the state governments. They are worried that legislators will misinterpret the care they give. Certainly the legislative notion that ectopic pregnancies can be saved by surgically implanting the fetus in the mother's uterus is beyond ignorant. Physicians are worried about life in prison. They’re worried about the threats to their lives as they know them. Making physicians more afraid isn’t going to fix anything. What is fundamentally missing with government programs billed as attempts to fix healthcare is problem-solving. In some states, neighbors can report neighbors to the Attorney General. These kinds of activities should never be established.

With the legislative decisions about saving ectopic pregnancies, it's no wonder women are having trouble finding care for problems which used to be treated by physicians but now carry threats of prison.

Physicians have always considered miscarriages and ectopics as well as conditions threatening the life of the mother as medical occurrences which should be treated. The problem here is the legislative lack of any real knowledge of medical conditions, diagnoses, or the treatments. Legislatures react to politically motivated demands that have no basis in sound medical preactice.  Medical decisions should be between a patient and a doctor, based upon physician knowledge, based upon the traditional patient-physician relationship.

Much has been written about the disappearance of the family physician and the patient-physician relationship. The destruction of this relationship is the primary cause of the disappearance of reasonable, affordable healthcare in the U.S.

I’m imploring state and federal governments to be constructive. Threatening doctors with undeserved consequences so they would prefer to send away a woman with an ectopic pregnancy rather than to take care of her is not problem-solving. It's politically motivated useless belligerence—and a travesty to healthcare.  

The problem here is the fault of the legislation, and not the fault of the provider or the patient.  For many physicians, the better choice is to stop practicing medicine. Real problem-solving in healthcare will only come when the real problem, the destruction of the patient-physician relationship is recognized as the basis of all that is wrong today in healthcare. Fragmentation and deprivation in primary healthcare is particularly hard on the practice of obstetrics and is a primary factor in the U.S. high maternal mortality rate. It's time for legislatures to wake up and take responsibility for destroying healthcare. But to do that, legislators would have to understand how they are destroying healthcare by taking medical decisions out of the hands of physicians. Elizabeth Rosenthal in her book An American Sickness calls for consumers to demand change from their legislators. She believes the only way to get the corporate profiteering out of the healthcare system is for individuals to demand far-reaching reform from their legislators.

But for legislators to bring about the needed reform, they must understand that the patient-physician relationship is the basis of good health care and take action to restore that relationship. Legislatures must understand, as Arnold Relman, the emeritus editor of The New England Journal of Medicine, said in 1985:

Reform of our health care system, if it is to be successful must address the problems caused by allowing a social need to be supplied to consumers as if it were a manufactured commodity.
Modern Medicine: What You're Dying to Know, p. 59.

As Elizabeth Rosenthal says, only consumers can put pressure on legislators to act responsibly in restoring the patient-physician relationship—the basis of good healthcare.

Thomas Huddle in "Doctors Should be Political, but not Political as Doctors" takes a detailed look at the place of politics in medicine. It should be a must read for every legislator.

Time for legislators to let consumers be patients and physicians be physicians.