April 16, 2001 -- A strong relationship with your doctor doesn't just make office visits more pleasant -- it's key to having better health. But how is this possible in today's environment, when healthcare seems to be getting ever more streamlined and impersonal?
"It is a collaborative [relationship], not us vs. them," Zeev E. Neuwirth, MD, tells WebMD. "If you approach physicians with this idea, tell them 'I want us to be on the same team, and working together. I want to get to know you, and I want you to know me, and I want for us to be more than cogs in this healthcare machine.'"
Neuwirth, an internist and medical educator at New York's Lenox Hill Hospital and assistant professor of medicine at New York University, is an expert in doctor-patient relationships. So are University of Chicago professor Wendy Levinson, MD, and University of Rochester professor Anthony L. Suchman, MD. All three agree that the doctor-patient relationship has a direct effect on the patient's health. And all three say that lots of things have to change.
The Accountant Will See You Now
Levinson worries about one recent development: the influence of money on patient trust in their doctors. At a recent meeting of the American College of Physicians/American Society of Internal Medicine, she talked about her ongoing research in this area.
"What was really striking to us was that doctors told us repeatedly that managed care and financial arrangements were really affecting how they viewed their role [with their patients]," Levinson says. "One doctor said he felt like a vending machine. He said that patients were coming in with lists of medicines and they really wanted him to just give them what they needed. There is real groundswell among physicians in how they see their role changing to being such a vending machine instead of a trusted advisor."
Suchman agrees. He says that the current healthcare system that stresses cost containment over patient care has created an artificial environment where a doctor can no longer see a patient as real person, whether they want to or not.
"I worked for 15 years studying my own patient-communication skills and learning how to teach them [to others] -- but after all that work I didn't see the [healthcare] world changing very much," Suchman says. "I began to see how healthcare organizations treat people: they create this force field of depersonalization. So if you are depersonalized, it is hard to treat your patient like a person. On the emotional and interpersonal level, the practice of healthcare [today] is primitive."
The Well-Informed Patient
Levinson, Suchman, and Neuwirth each talk about how the roles of doctors and their patients are changing. They all say one factor in this changing doctor-patient relationship is the rise of Internet health sites that provide patients with state-of-the-art health information.
"Patients want to play an active role [in managing their health] -- they now say, 'You are not doing anything to my body without me understanding it and going along with it,'" Suchman says. "As patients are changing their role, the question is how that affects the role of [healthcare] professionals. The current model of medical professionalism sees a person who becomes a patient as helpless, dependent, and passive. Can physicians shift out of that role to lift patients up rather than hold them in a passive position?
"Well, I find this new role more satisfying," says Suchman. "I get a partner instead of a person on my shoulders. But there has to be a change in expectations [on the part of the patient]. If the patient is going to think I am an idiot for not knowing something, I am not going to want him to look on the Internet. And I think we both lose in that case."
Neuwirth says that the patient and the doctor each have to take responsibility for changing the nature of their relationship -- even if the current state of healthcare makes that difficult.
"The system is fixed against improving the doctor-patient relationship, and people have to be creative to change that," he says. "I think patients have the ability to stand up and speak for themselves. They can say 'I want' a certain amount of the time: 'I want you to listen to me, I want to ask you a certain number of questions. We can visit more frequently, or do it by phone, but I really want this kind of interaction with you.' And there are people who do that."
Power to the Patient!
Levinson notes that patients come in to their doctors' offices with expectations and beliefs about what will happen. For her, the issue is a practical one: how will the doctor and patient negotiate differences of opinion?
"One of the strategies I really have enjoyed using is asking the patient about the invisible third person in the room," she says. "That is the person who before the patient came to the doctor said to them, 'Remember to ask about such-and-such.' I like to ask patients, 'who do you talk to about your healthcare.' And they say, 'Well, I talk to my Aunt Marge, she's a nurse.' And so I say, 'What do you think Aunt Marge might think about this therapy we are talking about?' That sounds convoluted, but it is a lot easier to disagree with the doctor through an invisible third person and challenge what the doctor is telling you by saying your Aunt Marge might not agree with the treatment plan."
Suchman advises patients to think hard not only about what they want to get from their relationships with their doctors, but what they are willing to contribute.
"The first thing is defining your own values, then being willing to step up to the process of partnership [with your doctor]," he says. "You have to be willing to advocate for what you are looking for, to give feedback to your doctor -- to help your doctor help you the way you like to be helped. If someone just says they don't like the way I communicate, I don't have the chance to change. But if a patient tells me that I made a mistake and I respond to that, it is a moment of truth. I can build more trust than if I didn't make a mistake in the first place. So instead of taking the passive role of patient, people should be willing to play a more active role, and then see how the doctor is willing to respond.
"The point of this is for patients to use their power," Suchman continues. "Patients have a lot of power -- not total power, but what they have now has to get a lot stronger. But even at the individual level people have the power to change the kind of care that they get. People need to understand that they are the first person in charge of their health. It is not their doctor, not someone else. They must recognize this role and actively think about it."
All In The Family
Neuwirth stresses the importance of involving family members in the healthcare process, particularly when the patient is ill.
"When a family is involved in a patient's care, you have people who see what is going on, and that changes the relationship in a very positive way because the physician sees himself in a different way, as a part of a group," he says. "And besides, you can't do it all yourself. The family can take notes, ask questions, look up things."
In the end, Neuwirth says, the ability for patients and doctors to improve their relationship depends on whether the society as a whole values personalized healthcare.
"If we as a society think this is important, we should create the situation that makes this possible," he says. "Telling doctors they should be relating to patients when they have to see a patient every seven minutes is impossible. It's worse, it is dehumanizing. If clinicians are suffering and stressed and frustrated, there is no way they can deliver quality medical care and no way to deliver the care on which the doctor-patient relationship is centered.
"If you are angry and scared and overwhelmed and burned out, how can you offer caring and kindness and compassion and anything that resembles healing to another human being," Neuwirth asks. "So the question becomes, 'Is that what society really wants from its doctors -- or do we just want technicians, and to go elsewhere for real care?' If we don't just want technicians, but also people who are able to be healers, we have to tend to that."