The Patient-Consumer

Every once in a while, I see an article in the news that discusses the roles that “e-medicine” and “telemedicine” play in delivery of medical care in the U.S. The articles vary in tone: some support these services as tools for patients to use to better prepare themselves for their appointments with physicians, while others condemn the services as being damaging or a hindrance to the patient-doctor relationship. I think my stepmom, a physician, approaches this in the best way. She tells her patients, “Bring in any information you find, and we’ll discuss it.” In doing so, she can take a positive stance on the patient’s proactive approach to their own care while encouraging the patient to be better educated about their health conditions, a goal that is ultimately at the heart of modern medicine (i.e. better education for better prevention and thus better health outcomes).

There appears to be a rising trend, though, of the introduction of new services that some perceive as being ways of eroding the power and influence of physicians – and the need for physicians. For example, a relative of mine, also a physician, had a startling encounter with Aetna, a health insurance provider. She has severe asthma, and she discovered during the care of her condition that Aetna was hiring nurses and sometimes social workers to dispense medical advice via telephone to patients in lieu of paying for patient visits to the doctor’s office. Two questions immediately come to mind: “While nurses probably have enough medical expertise to be able to advise on asthma care and the prevention of asthma exacerbations (attacks), do social workers have this knowledge? Also, is asthma ’sufficiently difficult’ enough to understand such that an appointment with a physician is necessary?”

Regardless of the answers to these two questions, two facts are very important to note. First, these nurses and social workers hired by Aetna can be seen as practicing medicine without a medical license, something that might be acceptable and under-the-radar with your own family and friends but isn’t acceptable on a professional level. Secondly, and more importantly in my opinion, organizations like Aetna and the patients who believe that this trend isn’t a bad thing are missing the importance and the uniqueness of the role of the doctor in the patient’s care.

At this point in my career, I have identified two aspects of care that physicians bring to health care that cannot be replaced or provided by any other health care provider:

1. Medical Expertise

No matter how well-educated a patient may be, the expertise of a physician in her field is paramount to any other opinion or deduction. Even physicians as patients must seek the medical advice of other physicians when the health condition is outside of their own discipline. Why? The physician is extensively trained to provide medical care in a particular area, and you want to give yourself the best chance of recovery. This is the same as in any other field: for example, you wouldn’t want to defend yourself in court if you were going against the best prosecutor in the world, and in the case of health, the opposing side always has the advantage if you’ve come to the point where you are seeking medical advice from anyone. You want the best advocate, the best player on your team, the one who will work with you to make the best outcome happen. Nurses, social workers, and others simply don’t have the same extensive training, and as amazing as they are in providing care for patients (in some areas and roles, much better than physicians), they don’t have the bank of knowledge, and more importantly, the clinical diagnosis skills to provide the best medical care possible. Even if all of the medical knowledge ever used in the care of patients is available on the web, patients, nurses, and others don’t necessarily know where to look and how to put all the information together. This is not to say that physicians are the stars and kings of health care: the fact of the matter is that of all the various niches in medical care, the physician is one that is completely irreplaceable, even based solely on the technical aspect of medical expertise alone.

2. Guardian Angel

However, the part that most people miss is not the medical expertise that physicians have, but rather it is the difficult-to-describe aspect of the patient-doctor relationship which I think of as being the role of the physician as a guardian angel for the patient. As much as other sectors of health care (from HMOs to hospitals to pharmaceutical companies to unappreciated nurses) attempt to insert themselves between and exert influence over the patient and the doctor, the most valuable asset the patient has in U.S. health care is the patient-doctor relationship.

Being sick or injured is inevitably a stressful, if not traumatic, experience for every patient. In approaching this experience, some patients choose to guard themselves from what they see as being the hassle, inconvenience, and expense of health care by taking on the role of an angry and demanding consumer – they want results, not fluff and broken promises. While I understand this sentiment from having sat in waiting rooms for hours at a time and having felt unsatisfied by the explanations doctors and nurses have given me as a pediatric but intelligent and conscientious patient, this approach will ultimately be disastrous for the patient – perhaps not on an individual level, but definitely collectively and with increased risk as time goes on. Being guarded may help when health problems are relatively minor. However, the more you guard yourself (as opposed to simply being proactive and open-minded), the more likely you run the risk of suffering severe psychological and physical damage when you are very sick. Most people underestimate the extent to which psychological stress can be physically debilitating, and this may be a powerful factor that influences the health outcome of a patient in a life-or-death situation (or perhaps a healthy-life-or-disabled-life situation).

However, there is another way. The patient-doctor relationship is multifaceted, but many people only observe the transfer of knowledge because they believe the relationship is strictly transactional. It can be, but this is at the risk of the patient. It ultimately is important for the patient to be well-informed, but this shouldn’t be used (or perceived by doctors) as a way of supplanting the doctor’s role in health care. No one, after all, wants to go through 4 years of medical school, 5-7 years of residency and subspecialization, and another x years of practice just to be able to self-diagnosis and self-treat, especially since you wouldn’t know going in what disease you’re going to have. As knowledgeable as you are, you need to trust the physician that uses her judgment wisely (which will be the vast majority of physicians) because they want to be on your side, and you also really should want them to be on your side when you’re sick. You can never be as confident in the advice of any other health care provider, be it a nurse, an alternative medicine practitioner (which I personally have experienced and appreciated), or other, and when dealing with disease, you want to start off on the right foot right at the beginning before it’s too late. While I don’t think that physicians should be seen as saviors, it would be just plain dumb for patients to see themselves as being merely clients. When standing on the edge between life and death, health and disability, what would you rather have: a lawyer or a priest? Trick question – a priest might help with the afterlife if you believe in that, and a lawyer can’t help you if you’re dead. You want a doctor who can stand beside you, hold your hand, and help pull you back from the disease. Doctors are unique in the role they can play and have played in health care, and it would be a disadvantage for all to have the patient-doctor relationship continue to erode or have it be removed entirely.

To future physicians: reach out to your patients, be patient with them, and help them learn and know that you are there for them, as much as they might be hesitant to trust you. No other word can describe your relationship to them besides “doctor” – it’s what you are, what you must be to them, and what cannot be replaced.

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