Monday, February 17, 2014

What is the Value of the Doctor/Patient Relationship?

(In response to Abraham Verghese's TED talk)

Verghese's talk centers on the process of the physical exam, but I think the central themes are that of ritual and connection.  In the healing relationship that physicians (should?) attempt to develop with our patients, the ritual and roles of healer and patient--those who are present to aid and to care and those that are seeking assistance and caring--enhance the physician's presence to beyond a source of a prescription or a recommendation for a treatment.  Instead, the ritual helps establish a connection between the two parties, and the connection enhances the benefit of any recommended treatment be it medication prescriptions, physical therapy, or counseling.  If a great deal of illness is suffering, then it is the trust between patients and physicians that helps the dyad seek to overcome that suffering.

I have long held tight to the concept of the "therapeutic use of self", that as healers we can use our presence to be an important part of helping patients heal in some form.  Verghese's closing--that physicians will not abandon our patients, that we will see them through whatever trial--beautifully summarizes this idea.

Unfortunately, we are in a situation in healthcare where it is very difficult to live up to Verghese's ideal.  I certainly cannot give 1 hr for a patient to tell me their history, and then another 1 hr visit just for the physical.  Our office gives us 20 minutes for each visit (whether a new or an established visit), and this is generous: many other offices give 10-15 minutes.  I can try to approximate Verghese's approach by taking advantage of the continuity of care primary care offers: I can see patients back repeatedly, and even if I cannot gather all this information at once or develop the desired connection as quickly, I can still work to gain my patient's trust and to preserve the healing relationship heading forward. 

In a healthcare system that rewards productivity, physicians will be pushed to be productive.  Often this means seeing more patients, ordering more tests, sending for more studies…and often times the therapeutic use of self is left aside in the hustle.

Relationships are critically important, and so are patients' expectations and experiences.  In the case of research around the placebo effect it appears that how much benefit a patient receives from certain interventions depends on their experiences.  If we as physicians are caring, kind, patient, and truly interested, might we enhance this benefit?

I believe the issue at hand is that we have a healthcare "system" that is not a system, and that does not really care about "health".  If we cared about health, we would emphasize the importance of the doctor/patient interaction, we would give the time needed to allow this relationship to develop and be supported, and we would find a better way to value the work being done.

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