The doctor-patient relationship is central to the practice of medicine, and is one that has evolved over time. In the past, ailing patients expected the doctor to treat their medical conditions and assuage consequent psychosocial concerns. These patients bestowed trust upon their physician because advanced medical knowledge was not easily available to the general public, and because patients’ knowledge about their medical conditions was derived primarily from their doctors who were revered as fonts of knowledge within society.
The power granted to the erudite doctor shifted the burden of illness from the patients to the doctor, and the patients felt better because doctors offered explanations, and therefore hope and support for healing. In return, payment as currency or material items/services was made directly to the doctor. With medicine being art as much as science, the doctor met the patients’ expectations since the patients’ medical realism relied upon direct communication and education by the doctor to the patient.
The doctor-patient relationship has evolved into a “healthcare service provider-consumer” relationship, and legitimate patient education has waned. Rapid advances in technology and social media have altered the dynamic of the sacrosanct doctor-patient association. The constant ability to communicate via any number of means (texting, voice, social media, etc), all through a personal mobile device, has fundamentally changed what society views as a meaningful relationship. This constant and immediate ability to communicate has created a desire for instant gratification. People now expect 24/7 virtual availability, rather than taking the time to develop a close relationship with one’s personal doctor through face-to-face encounters. In this new era, what was once a deep personal relationship becomes a simple mechanical interaction, not unlike “buy now” or “chat now” buttons on websites or via in-person instant appointments in department store clinics. Instead of direct communication and education by doctor to patient, instant access to information and adoption of virtual or transient relationships has resulted in education of patients by any number of “healthcare service providers”, such as Google and WebMD.
Similarly, the increasing demand for healthcare services has led to necessary changes in the payment model in the USA. Further inadvertent disruption of the doctor-patient relationship/education has accompanied the introduction of the insurance intermediary. The vast amount of money in healthcare has resulted in a situation where the business of healthcare has demeaned doctors and patients to mere service providers and consumers. Medical treatments are now “healthcare products”, and hospitals and health systems are now “healthcare ecosystems”. This terminology has depersonalised the doctor-patient relationship and contributed to the perception that healthcare is simply a product that can be bought and sold, not unlike buying and selling cars or home products on Amazon or Craigslist. Companies now show costs alongside healthcare, so that patients can choose treatments on a financial basis, with education being provided by “consumer” reviews. Consumers of healthcare seek to establish quality of care through the same means that it is established for other services. Rating systems for healthcare service providers are now available on business rating websites such as Angie’s List and similar services. US News and World Report rank hospitals and specialties annually, and preliminary results (personal communication) from a survey of patients and providers indicate that such rankings are primary quality indicators—perhaps by default, because valid medical education by doctors to patients has been compromised to increase the efficiency of the virtual healthcare industry. Although virtual healthcare can be cost-effective in many aspects of medicine, it is as yet impossible in surgery as its very nature requires an intimate doctor-patient relationship with retention of direct education to avoid patient misconceptions, unrealistic expectations, and poor outcomes.
A significant example of patient misconception/poor education was presented in a recent report.1 In a survey of patients presenting to a general neurosurgical spine clinic at a tertiary care centre, more than 50% of patients indicated that they would undergo spine surgery based solely upon imaging abnormalities, even without symptoms. If the patient has no symptoms, what does the patient expect to gain through undertaking the risk of surgery? Should surgeons treat imaging reports rather than patients? Virtual medicine would favour the former, but ethical surgery would favour the latter. Further patient misconception is reflected in the 1/3 of patients who believed that back surgery was more effective than physical therapy in the treatment of back pain without leg pain, and the 17% of patients believed that back injections were riskier than back surgery. These misconceptions were even noted to persist in patients who had already undergone previous spinal surgery. Similarly, a study of patient education aides found that 70% of patients believed CT or MRI results were more important than a physician’s examination in deciding the appropriateness of surgical intervention.2 With misconceptions such as these, it is no surprise that another report found that a surgeon’s recommendation against surgical intervention was associated with lower satisfaction scores in patients with spinal disorders.3 Poor patient education leads to patient misconceptions, unrealistic expectations, and lower satisfaction.
Lower patient satisfaction has considerable implications for both patient outcomes and for the medical community. The Centers for Medicare and Medicaid Services (CMS) rates providers through the Clinician and Group Consumer Assessment of Healthcare Providers and Systems (GC-CAHPS) surveys based on patient experiences. Similarly, the Hospital Consumer Assessment of Healthcare Providers and Systems (H-CAHPS) survey rates hospitals via consumer reporting. This information is not only being utilised in decisions regarding hiring of doctors but is also being tied to physician reimbursement. The CMS website notes that the “CAHPS surveys are an integral part of CMS’ efforts to improve healthcare in the USA”. Some CAHPS surveys are used in value-based purchasing (pay for performance) initiatives rather than in fee-for-service reimbursement—instead of only paying for the number of services provided, the quality of services provided is a more valued but ill-defined parameter which requires further investigation. Quantitative and qualitative studies geared towards identifying key concepts related to patient/consumer satisfaction can be used to refine our understanding of value in medicine. Until quality of healthcare is reliably defined, the current system of poorly-educated consumers (patients) with significant misconceptions who are purchasing healthcare products (medical treatments) from a service provider (surgeon) will lead to a failure to meet their expectations, resulting in lower satisfaction and further degradation of the necessary intimacy of the doctor-patient relationship.
The underlying scourge of medicine today is the lack of valid patient education, but this is also a prime opportunity for our profession. The original role of the doctor was not only to heal and comfort patients, but also to teach them. Indeed, the word doctor is derived from the Latin docere—to show, to teach, cause to know. We must teach, educate, and inform our patients in an unbiased and respectful manner while retaining the dignity of the doctor-patient relationship. As society evolves with technology, we must educate by appropriately employing new means of communication at our disposal, such as face-to-face video communication, email, websites, mobile applications and other technologies to enhance efficiency. However, we doctors should remain the primary medical educators. If we do not teach our patients, then we are just service providers who deliver a product to the consumer within the healthcare ecosystem and industry. Doctors can and should continue to teach patients and counsel them about their treatments, so that patients can make rational decisions about their treatment plans. The restoration of the doctor-patient relationship based in education and trust will improve patient satisfaction and outcomes to define true value in a value-based purchasing system. Only we have the education, training, and clinical experience to be able to do this, and only through teaching can we re-establish that central doctor-patient relationship that has long comforted and healed patients.
- Franz EW, et al. J Neurosurg: Spine 2015 27:1–7.
- Deyo RA, Cherkin DC, Weinstein J, et al. Med Care 2000 38:959–969.
- Mazur MD, et al. J Neurosurg: Spine 2015 20:1–6.
Cheerag Upadhyaya is a neurosurgeon at Saint Luke’s Marion Bloch Neuroscience Institute, University of Missouri, Kansas City, USA. Kate W-C Chang is a researcher, Donald Tomford is a chief department administrator and Lynda J-S Yang is a neurosurgeon, all at the Department of Neurosurgery, University of Michigan, Ann Arbor, USA