The Value of the Physician-Patient Relationship

In an age of metrics and data, it is almost impossible to quantify the importance of relationships.  When reading the article,“Trying to put a value on the doctor-patient relationship”, in the NYTimes, I recall thinking well of course there is value to the physician-patient relationship.  It seems like a no-brainer, but how can you prove it. I cannot think of any physician who would argue that having a long-term relationship with a patient they have known over time and understands their family dynamics and personal stressors wouldn’t have a more solid base to draw upon.  The problem is how do you quantify it? How do you put a measure on a personal connection, on the ability to learn nuances about someone’s personality or the trust that develops over time between two human beings. Dr. David Meltzer, an economist and primary care physician attempted to do just that.  The results of his study supported his theory that strengthening the relationships between patients and their physicians can decrease medical costs and improve patient health. This is music to the ears of administrators whose primary goals are to improve outcomes and decrease costs.

But what about for the patient?  From personal experience I have seen patients crave personalized attention in our broken healthcare system.  With the push for corporate branding over the personal relationship between a patient and their doctor; patients are feeling like they are just a number.  They are shifted around to other “providers” for convenience and I believe to strategically destroy the bond a patient has with their physician and coerce their allegiance elsewhere.  Patients who are part of large healthcare organizations are not longer Dr. So and So’s patients but rather the patient of ACME healthcare. Patients don’t understand this, they come to us because their neighbor or friend recommended a specific physician to now find they are just a part of a large organization.  If their physician is fired or leaves the group they are many times given no explanation or information of how to follow that doctor; rather they are randomly assigned to a new “provider”.

Corporate medical institutions and insurers count on this.  They love the ability to manipulate patients at their whim. They do not want patients to have an allegiance to their doctors, otherwise they lose all the control.  As more and more physicians became employees it is harder and harder for them to have any direct control over their practice. With productivity demands, time constraints and so many interferences (EHR, regulations, etc…), physicians are losing the ability to develop these ever important relationships directly with their patients.  Our schedules are packed so tight, we find it difficult to add on sick patients who need to see us. With the implementation of patient call centers, patients are now diverted from being able to speak directly with the office staff who know them, to being funneled to eagerly waiting walk-in clinics and urgent care centers many times staffed with less qualified providers who do not have these established relationships.  This many times lead to delays in care and missed diagnoses.

Relationships are equally important for physicians.  Rushing people through, day in and day out, merely trying to get a glimpse of their health concerns and find a quick diagnosis to treat or more complex problems to refer.  Physicians do not have the luxury of time to let patients explain what ails them. I recall from medical school that if you listened long enough to the patient’s story, they would tell you what was wrong with them.  But in our current healthcare climate of 7 minute visits, patients are cut off too soon. Physicians are not given the time to properly examine and develop a differential diagnosis or the time to implement an appropriate plan of treatment.  We are not able to utilize the full extent of our knowledge since referring a patient to a specialist for something we could manage takes less time and is more efficient. Our time is cut short and documentation demands too high. We lose a critical part of what makes us a great physicians and that is the rapport we develop with our patients and the insight gained by seeing them over time.  Loss of this ever important relationship with our patients is an important contributing factor to physician burnout.

Patients need these relationships with their physicians to develop trust.  Trust allows them to divulge information they may withhold from someone new to them.  Trust allows them to feel confident in our recommendations for care. Over time that relationship results in a mutual respect for one another and aids in shared decision making which facilitates patient compliance and empowers patients to participate in their own care.  Anecdotally, patients frequently tell me how much they appreciate the time I take to explain a recommended treatment. I give them the risks, benefits and alternatives. I discuss evidence based medicine, but I also share what I have seen from experience. Because of our relationship they trust that what I’m recommending is in their best interest.  They trust me to take care of their family members. For me these relationships are what keeps me going. It’s the joy I get out of being a doctor.

Will we ever have data to support the value of the physician-patient relationship?  The above article definitely gives it some credibility. But for those of us practicing physicians, I say who cares.  Why do I have to prove to anyone other than myself and my patients that the time I spend and the relationships I develop with them needs to be quantified.  If these relationships make me a better doctor and my patients are getting better care for it, that is all that matters.

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Jaclyn Nadler MD

Jaclyn S. Nadler, MD, MBA, FACP is a practicing internal medicine physician in Southwest FL. She received her medical degree from the University of Miami and undergraduate (BSN) and graduate (MSN/ARNP) training from the University of Florida in Gainesville. She attended residency at Wake Forest Baptist Medical Center in Winston-Salem, NC and completed her MBA degree with a concentration in medical management from UMass, Amherst. Dr. Nadler recently joined the Direct Primary Care/DPC movement when she became disillusioned with the current state of healthcare including physician abuse, corporate medicine’s focus on quantity of care over quality and the loss of physician autonomy. She started her own DPC clinic, CoastalMED DPC in January 2019 where she can practice medicine on her own terms and provide her patients with the time and superior care they have grown the expect. She is passionate about physicians regaining their rightful place at the helm of healthcare and physicians reverting back to independent practice and regaining autonomy. She is a member of the Florida Medical Association and Direct Primary Care Alliance, she is a Fellow in the American College of Physicians and received her certification as a physician executive (CPE) through the American Association of Physician Leaders. You can learn more about Dr. Nadler and view her blog at www.JaclynNadlerMD.com 

  3 comments for “The Value of the Physician-Patient Relationship

  1. Natalie Newman
    May 27, 2019 at 10:21 pm

    Advances in technology, metrics, AI, etc. are impressive. Exciting. Until you become the patient. Nothing replaces the human to human connection when patients are at their most vulnerable. There is no adequate substitute. Period.

  2. Steve O'
    May 27, 2019 at 11:23 am

    PS: All too often, some technocratic dimbulb replies to this line of argument with the condescending assurance that the biosphere is turning into the technosphere everywhere, and only Luddites and superstition fogies don’t see the massive efficiency which modernization has imparted over so many things.
    The profession is ground under by the ignorance that IT is a tool, like a retractor. Tools never add value; it is by their use that processes may be improved.
    I use an insanely simple and versatile open-source programming language called AHK, or AutoHotKey, to expedite nearly everything that calls for repetitive entry of mindless details on the computer. I use AutoHotKey here to sign by entering my nom de plume details, right here on the authenticmedicine site!
    It would be incredibly easy and useful to use this language on an EMR at work. All of those banging through computer-generated checklists of dreck can be solved by making the damn computer fill out the damn forms that it generates!
    Except where I work, AHK is only permitted for the use of the IT gnomes. For a long-suffering provider to create AHK files or executables is considered malicious hacking by the organization. Fair enough. I consider their use of computers to be malicious hacking of my patient care. But they pay my salary, so I meekly avoid efficiency when scolded not to use it.

  3. Steve O'
    May 27, 2019 at 11:03 am

    It seems absurd to try to assess a value, or rather a price, to the doctor-patient relationship. It is like asking – “What is the price of the internet?” or “What is the price of the Sun?”
    The doctor-patient relationship is a dialectic, which is an old philosophical term ground into meaninglessness by the Marxists. It is a discussion which yields insight.
    In the legacy of factory economics, things have a cost, which can be reduced to yield increased profit if the changes preserve the effectiveness of the item in question. The stupid corollary of this is “quality harvesting.” If you degrade the quality of something, it must become cheaper, no?
    To price something out, means either that it has an actual exchange of service for money in the marketplace, like DPC; or that magicians come up with a formula that assigns a “price” to something. Industrial production in the Soviet Union consisted of a central bureaucracy which effectively assigned the price of everything. That is why steak was so cheap, but you couldn’t get it.
    If someone prices out the cost of testing for a disease, the cheapest way by far is to visit a physician who one has seen for some time. Neither a TSH nor an MRI yields as effective a diagnostic tool as the history of the experienced physician. But since these things are more expensive, people imagine that that makes them “better.”
    Medicine has become like a posh seance, and if the cost of the medium is substantial, the spirits from beyond had better emerge; and they dutifully do so. Prescriptions are written, everyone is happy, as long as someone else is paying for the clairvoyant.

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