Running head: DECLINE OF THE DOCTOR PATIENT RELATIONSHIP

The Decline of the Doctor-Patient Relationship and The Effects of Various Components on Finding a Solution Caitlin Courtois Northeastern University

DECLINE OF THE DOCTOR-PATIENT RELATIONSHIP Abstract

The issue of communication and its shortcomings in the healthcare system of America is quickly gaining prominence in the conversation regarding improving the quality of care delivered. It has become evident that this is as integral of a feature of the system as the biomedical knowledge distributed and acted upon in the realm of medicine. Unfortunately, there is a disconnect between doctors and patients, spawned by a number of environmental factors. Current research seems to be very limited in scope, focusing on specific aspects of the issue, and recommending solutions that are aimed at these prospective causes. This paper attempts to highlight the importance and logic in engaging all parties involved as a part of the solution. The topics covered include managed-cares role in causing this disconnect, medical schools curriculum shortcomings, as well as the deficiencies in patient behavior. Concentrating on these specific aspects should allow the reader to logically come to the conclusion that participation and cooperation from both sides is necessary in bridging this lethal communicative gap.

DECLINE OF THE DOCTOR-PATIENT RELATIONSHIP Introduction In todays age of seemingly inescapable banter of managed-care and healthcare reform seen on the news and any other media outlet, it is clear the focus has shifted from needs of patients to the impending issue of rising healthcare costs. No longer is the main concern of

physicians their patients, done away with by thwarting thoughts of fitting as many appointments in as possible to appease the companies that pay their salaries. Unfortunately, the age-old saying is true: time is money, and everyone, doctors and patients alike, are feeling the burn. Though it is inarguable that the astronomical cost of receiving healthcare is a debilitating matter, the effect of the complete focus on only this issue is breeding more problems that are exponentially increasing in severity. In the midst of the pressure placed on healthcare professionals by managed care companies along with the sense of carelessness bred by the resulting overwhelming stress they incur, it seems as though the relationship between the physician and patient is faltering and quality communication and understanding between these two parties are falling to the wayside. Both parties are dissatisfied and this issue is only adding to the diminishing excellence of healthcare in America. Efforts to calm this mounting storm of unrest have yet to find any widespread success. Faced with the possible destruction of the reputation of Americas healthcare system as a model structure, it is undoubted that a logical plan must be put in place to upkeep the level of quality of service delivered to patients in this country. Though most current research efforts have failed in recognizing both as integral contributors, this multi-pronged issue can be attributed to each of those involveddoctors and patients. As a result, cooperation of all parties involved in our healthcare system is necessary to make a change. Upon investigation of the various aspects of

DECLINE OF THE DOCTOR-PATIENT RELATIONSHIP this problem, it becomes clear that a comprehensive solution involving the accumulation and further development of current efforts will heed the highest probability of success. The Big Bad Wolf: Doctors? When a patient steps into a doctors office for assistance in a state of sickness, they are

granting this physician the upmost responsibility of providing to them the highest level of quality healthcare that their abilities allowexactly what is stated in the promises outlined in the Hippocratic Oath. Unfortunately what many are receiving is rushed visits, unnecessary testing, and an overall sense of carelessness from the physician. This can only result in poor patient outcomes, low patient satisfaction, and decreased adherence to a given medical plan by a patient. This is not an ideal situation for either party, yet it is a necessary evil placed on the healthcare system by the advent of managed care. These managed care organizations manipulate regulations they place on their networks to ultimately increase the use of primary care physicians as a type of gatekeeper for specialists (Grembowski, Patrick, Williams, Diehr, & Martin, 2005). The obvious effect of this is a higher patient capacity for physicians to maintain on a daily basis, which carries its own list of implications. In order to capably see the highest amount of patients in a day, these doctors are spending less time with each, and even carelessly overlooking important aspects of described ailments. Patients often times find themselves feeling like part of an assembly-line, discouraging their opportunity and desire to be a team-player in their care (Grembowski et al., 2005). In this way, efficiency is winning over perceived quality of care, and patients are becoming increasingly exasperated. In a study published by the Medical Care Research and Review, it was found that primary care patients that suffered from physical pain along with depressive, psychological symptoms, declared lower ratings of quality healthcare from the physicians in more managed environments than in those of lesser managed offices

DECLINE OF THE DOCTOR-PATIENT RELATIONSHIP (Grembowski et al., 2005). Though this study was very restrictive, not taking into account other medical issues or a wider range of patient demographics, it is still indicative of the type of dissatisfaction currently experienced by a great deal of Americans and is a great foundation for further similar studies that can address a larger patient pool.

Since it is not likely that managed care is giving up its reign anytime soon, it is necessary for doctors and other healthcare professionals to make strides towards improving their communication skills in spite of the overarching situation. If appointment times cannot be lengthened, the small time that doctors and patients spend together must be used to the utmost of advantage. For doctors, that includes directing the appointment in a way that delivers effective informative without taking away the time to touch upon the patients concerns and create a bond of trust between the two. A technique quickly gaining reverence is BATHE, a method created by psychologists that focuses on addressing physical symptoms by taking into account a patients emotional state as a way of catering care to their specific needs (Walton, 2009). The acronym stands for Background, giving the patient a chance to detail any underlying concerns or situations; Affect, allowing the patient to make connections between their emotions and overall state; Trouble, helping the patient to hone in on the predominant issues; Handling, to assist the patient in the idea of taking control of the issue; and Empathy, demonstrating understanding and setting the stage for a bond based on trust (Walton, 2009). Utilizing a questioning scheme such as BATHE is a way for physicians to take back their role as humans, rather than medical robots, and prove to their consumers that they are fully invested in their emotional and curative wellbeing. Other models similar to BATHE have been proposed, and the underlying theme is persistent throughoutincreasing patient comfort as a way to increase the satisfaction of and adherence to doctor instructions (Domingo, 2010). Though further testing and perfecting of these

DECLINE OF THE DOCTOR-PATIENT RELATIONSHIP methods is necessary, the need to reinforce doctors roles as empathetic beings is unwavering. Instead of sitting by the sidelines as victims of the post managed-care era, these health professionals need to employ the tools necessary to create the hospitable environment and communication level they feel has become unattainable. Medical School: The Root of the Issue? Though managed care seems to create a vast majority of the problems that many health professionals face in delivering quality medical care, it is clear that other factors may lend an unhelping hand in the issue. Often times it is overlooked that the training these professionals

experience might lead to the inexperience that is breeding communication issues between doctors and patients. During schooling, there is an increased pressure on those who design the medical curricula to keep up with technological advances. In the midst of the growing scope of scientific information that needs to be delivered students, less emphasis is being placed on explaining the importance of empathy, compassion, and quality communication, which includes the acknowledgement of cultural, language, and socioeconomic differences in patients. Though most medical schools in America require courses in clinical communication skills early on in the curriculum, it is often found that these ideals are not upheld in their clinical education rounds, rendering the previous courses insignificant (Rosenbaum & Axelson, 2012). When these students are being trained by current physicians who have no reverence to the importance of communication skills, a negative cycle is reinforced. Ignorance breeds ignorance. In a 1992 survey of medical schools in America, it was found that only 13% of these institutions offered courses in cultural sensitivity and clinical communication skills, leaving little opportunity for their students to become well-rounded physicians (Rosenbaum & Axelson, 2012). Since then, opportunities have increased drastically, but it seems to be the hidden

DECLINE OF THE DOCTOR-PATIENT RELATIONSHIP curriculum, rather than the formal, that is now falling behind the trends. This hidden curriculum has gained increasing respect as an important part of the learning experience for budding physicians. This includes the skills that students learn and reinforce outside of the classroom, through interactions with faculty, staff and patients in the context of clinical care (Rosenbaum & Axelson, 2012). Unfortunately, emphasis on biomedical information by these clinical instructors are breeding a hidden curriculum that no longer supports past humanistic learnings, and, in turn, ignoring the scope of communication in practice. In this way, it becomes the joint responsibility of clinical students and their mentors to observe, model, and reinforce quality and thoughtful communication skills in a clinical environment, as this will undoubtedly affect their communication with patients as future physicians. Though there is no evidence that much has been done to address this issue, efforts need to start with restructuring at the level of curriculum and standardizing clinical residency practices. It was shown in a study published in the Journal of the American Medical Association that first-year medical students exposed to a communications skills curriculum deeply improved their dynamic with patients, employing more relationship building practices and shared decision making by the third year compared to those students in the study that we re not exposed to the same classes (Yedidia et al., 2003).

During the posttest assessment on communication, the students in the experimental group scored on average, 5.1% higher than their other peers. This 5.1% serves as proof that changing the curriculum of medical school, though it may be a long as well as expensive process, will only help to increase the amount of communication-cognizant physicians in the future. This, along with motivating clinical educators to model their programs with better focus on humanistic skills, will provide students with an ongoing progression of strengthening the skills necessary to better their end of the doctor-patient relationship.

DECLINE OF THE DOCTOR-PATIENT RELATIONSHIP Patients: Part of the Problem Much of the current literature places an emphasis on the doctor as the facilitator of communication in the health-care center, skewing the responsibility of health maintenance in an unfair way. Patient-centered care, that which takes patient preferences and values into

consideration, is an impossible feat without the involvement of the patients themselves (Tinetti & Basch, 2013). It is outlined by the American Medical Association, that patients responsibilities include asking for clarification on doctor-given instructions, being active members of the decision-making process when it comes to the realm of their health, and to follow treatment plans given by a physician (Tinetti & Basch, 2013) An ongoing issue is the lack of patient compliance to physician instructions, especially those regarding medications, the postponement of seeking medical care, the lack of participation in screening measures, and the ignorance of follow-up care and appointments (Vermeire, Hearnshaw, Van Royen & Denekens, 2001). Though these issues can be the cause of a simple language barrier or other physical obstacles in obtaining care, much of the time resistance by the patient is to blame. Patient adherence is directly associated with outcomes in their care, and in this way, the patient ultimately bears the responsibility in the upkeep of their health. Previously, societal ideals have granted physicians expert and all-knowing status, creating a system in which patients found themselves submitting to doctors opinions without active participation in their own healthcare (Fong Ha, Anat, & Longnecker, 2010). Long gone are these days, tarnished by malpractice litigation and other scandals that prove doctors are no godlier than anyone else. Patients today are slowly beginning to assume the position of active members in the decision-making process of healthcare. They are evening out the playing field, asserting more dominance in the control of their bodies. With this comes resistance to the

DECLINE OF THE DOCTOR-PATIENT RELATIONSHIP opinions of the physician, sparked by the knowledge and information now available online and through other technological outlets. Armed with their own views spawned by their research,

patients may find themselves on the defensive, tailoring doctors instructions to fit their ideals, or even just discounting it altogether. Though this type of proactivity is welcome, it too needs to find balance with the advice of the doctor. A study was conducted in which female patients in the Appalachian region of the US were given advice on decreasing sun exposure, along with a description of the consequences that could arise as a result of continuing such behavior. What was found is that the patients ideals of being tan as a sign of beauty won out over the health benefits of avoiding the sun (Fong Ha, Anat, & Longnecker, 2010). Doctors had equipped them with the necessary information to the best of their abilities, lending evidence to the idea that the poor choices were rooted in the patients actions. It is clear that collaborative communication is crucial in ensuring quality health outcomes, with the key word being collaborative. A patients input, concerns and questions are all necessary in maintaining a two-way relationship. As soon as one of these fundamental parts neglects fails to cooperate or engage in active participation, there is a collapse of the teamwork that is necessary in improving the way healthcare is delivered, and accepted, in America. Employing tools such as the BATHE technique along with many other developing protocols that focus on how professionals can help to engage patients in healthcare, yet few focus on the accountability of patients to want to be engaged. Efforts such as attempting to increase health literacy as well as the use of patient-decision making aids that outline ones options are helping to present to patients the opportunity for them to take control and realize the potentially dominant position they can hold over their health. Unfortunately, many patients arent challenging the healthcare system or advocating for better-suited options because they dont

DECLINE OF THE DOCTOR-PATIENT RELATIONSHIP know how to or are unsure that it will make a difference (Arnold, 2007). Education is the only way to bridge this gap. Ultimately, in the event of physician failure to engage a patient, it becomes the responsibility of a patient to come off of the sidelines and become an active member of the

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healthcare community. The University of Rochester Medical Center outlines methods for doing so, including writing down any questions for a physician prior to meeting with them, keeping a health diary, answering their questions honestly, following instructions, keeping appointments, learning about conditions they may have or medicines they take, and being honest with the doctor and themselves about their abilities and limitations in participation in any given health plans (How to be an Active Patient). Being proactive, sharing specific needs, and utilizing the tools that advancements in technology have provided are among the many ways patients can help to chip away at the issue of deteriorating communication between doctors and patients. Looking Toward the Future Though the situation might seem grim when looking at current and past trends relating to doctor-patient communication, there is a sense of encouragement provided by the efforts already put into place. As previously discussed, initiatives have been set up to tackle the issue separately from all sides, yet none seem to possess the cohesiveness between all aspects that is necessary to disseminate the problem effectively. By placing the blame or focusing a solution on one facet of an issue that is multi-pronged, it leaves the opportunity for other shortcomings to grow in depth of negative consequences. A study published in the Official Journal of the Medical Care section investigated the evolution of the doctor-patient dynamic and its effect on patient outcomes. It was determined that more patient control, more affectespecially [that] expressed by physicians and more information provided by the physician results in a better subsequent

DECLINE OF THE DOCTOR-PATIENT RELATIONSHIP

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health status of the patient (Kaplan, Greenfield & Ware, 1989). This implies that both doctor and patient behaviors are key aspects to an effective healthcare relationship, and further illustrates the need for medical education to reinforce these ideals. Overall, fixing the problem that is the death of the doctor-patient relationship starts with the avoidance of using the term problem. This word indicates that there needs to be blame placed on someone or something, and unfortunately we have failed in identifying exactly who to put this burden on. It is not on the shoulders of doctors or patients alone to fix, which has been seen in past trends. This requires the equal effort from both parties, set in the training of current and perspective physicians with the notion that managed-care will be an enduring issue, along with the engagement of patients to take an active role in their healthcare. The lack of solid research and investigation surrounding all facets discussed in the decline of the doctor-patient dynamic may be considered a roadblock for some, but can also be viewed as an opportunity. Through further trial and error of different combinations of projected solutions, a more logical, comprehensive resolution can arise. Only by uniting the efforts of many will we see a reincarnation of the doctor-patient relationship.

DECLINE OF THE DOCTOR-PATIENT RELATIONSHIP References Arnold, S. (2007). Improving Quality Health Care: The Role of Consumer Engagement. Retrieved March 14, 2014

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Domingo, C. (2010). Doctor-Patient Communication in the Medical Interaction: Context, Implications, and Practice. University of Texas School of Public Health.

Fong Ha, J., Anat, D. S., & Longnecker, N. (2010). Doctor-Patient Communication: A Review. The Ochsner Journal, 10(1).

Grembowski, D., Patrick, D., Williams, B., Diehr, P., & Martin, D. (2005). Managed Care and Patient-Related Quality of Care from Primary Physicians. Medical Care Research and Review, 62(1), 31-55.

How to be an Active Patient. University of Rochester Medical Center Health Encyclopedia.

Kaplan, S., Greenfield, S., & Ware, J. (1989). Assessing the Effects of Physican-Patient Interactions on the Outcomes of Chronic Disease. Journal of the Medical Care Section, 27(3).

Rosenbaum, M., & Axelson, R. (2012). Curricular disconnects in learning communication skills: What and how students learn about communication during clinical clerkships. Patient Education and Counseling, 91(1), 5.

Tinetti, M., & Basch, E. (2013). Patients' Responsibility to Participate in Decision Making and Research.The Journal of the American Medical Association, 309(22).

DECLINE OF THE DOCTOR-PATIENT RELATIONSHIP Vermeire, E., Hearnshaw, H., Van Royen, P., & Denekens, J. (2001). Patient adherence to treatment: three decades of research. A comprehensive review. Journal of Clinical Pharmacy and Therapeutics, 26(5), 331-342.

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Walton, I. (2009). Consultation skills: Using the BATHE technique. Independent Nurse.

Yedidia, M., Gillespie, C., Kachur, E., Schwartz, M., Ockene, J., Chepaitis, A., . . . Lazare, A., Lipkin, Mack. (2003`). Effect of Communications Training on Medical Student Performance. Journal of the American Medical Association, 290(9).

Reflective Note: This piece will definitely fit into my professional portfolio, as it outlines the importance and implications of quality communication with patients. This ties into the theme of my other projects and is an overarching research document that supports prior work.