April 1999 Bulletin

Physicians must put patients first in partnership to rebuild trust

We, as physicians, are encountering significant challenges to our ability to deliver appropriate, sometimes even adequate, health care to our patients. Our practices are being constrained by these difficulties, some of which, admittedly, are of our own making. However, most have been thrust upon us. We have often failed to confront these challenges and turn them into opportunities to provide the best care for our patients. It is time we placed our patients first.

It is becoming obvious to our patients that insurance companies are not at all interested in the quality of health care that patients receive ... only that the cost of that care is significantly less than the sum of the premiums the companies receive. This reality is not going to change until physicians and patients form a partnership that "managed care" cannot withstand. Managed care, by virtue of its cost-consciousness, is making decisions for our patients, decisions that the patient-physician partnership should be making.

Patients want to be empowered, they want to take responsibility for their own care. But, our patients have become alienated and feel disenfranchised from the management of their own health and well-being. Today's patients are infinitely better informed than the patient population was 10 years ago; they are researching their own health issues through a variety of sources that are now available to them, e.g., the Internet. No longer are the physicians the sole source of knowledge about the patients' treatment. Unfortunately, in many cases, patients encounter, and sometimes believe, misleading and/or erroneous information from alternative medical providers who can make success claims that we physicians, ethically, cannot. Armed with these claims, they come to us confused, at best, and sometimes hostile. Our treating these patients with "benevolent paternalism," discounting the alternatives without explaining all options with them, breeds mistrust and a loss of our credibility in their eyes. Our patients are no longer willing to put their complete faith in our ability or willingness to put their needs and wants first. This responsibility should lie with the patient.

What do our patients want? Basically, they want to feel cared for. As part of that experience, they expect to be listened to. We need to consciously make the effort to understand our patients' goals and desires, and to honestly answer their questions. They want to participate in a dialogue concerning alternatives, a discussion that gives the words "informed consent" validity. We need to take time and offer information upon which they can base an intelligent decision. Patients want to avoid surgery, if that is possible. We, as physicians with surgical capabilities, should respect their desire for the most conservative treatment first, even if we believe that eventual surgery is the most expedient treatment.

In order to improve our communications to make our patients understand that we do care, we must understand how they comprehend our medical jargon. But, more importantly, we must understand their needs. We must change our monologue into a dialogue.

If we are to earn back the trust of our patients, we need to embrace the philosophy that patients are capable of, and should be responsible for, making important and complex decisions about their health care. Because patients experience the consequences of having diseases and injuries and being treated for them, they have the right to be the primary decision-maker regarding their health problems. We are their facilitators. There is no doubt that our education and training puts us in the unique position to help patients with these decisions. Our role, however, should not be to thrust our decisions upon them, but to share that knowledge so that the decision will be made by informed and confident patients.

How do we improve patient communication and education in the decision-making process? It is as simple as putting the X-ray up and looking at it with the patient. Discuss it with him or her. It is only the occasional patient who wouldn't want you to do so. Share both the operative and the nonoperative possibilities of remedying the problem. The more information you impart, the more comfortable your patient becomes. Investigate the alternative therapies that the patient has downloaded from the world-wide web, and find out why it would or would not be appropriate in the patient's case. The patient then feels in more control of his or her health care, and feels included in the decision process.

As physicians, it is our vocation and our duty to keep the patients' well-being first and foremost in our practices. It is time that the patients are reminded that this is just the case. We can no longer assume that he or she won't or can't understand the factors which affect the state of his or her health. In this age of the information superhighway, we should be the first stop the patient makes. With the involvement of our patients in their own care will come a return of trust in us as physicians. We must remember to always hold a patient's hand, but a scalpel only when needed. We need to put the patient first.

Robert D. D'Ambrosia, MD
President


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