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Grand Rounds #52 (The Carnival of Caregivers)

Is the Doctor/Patient Relationship in the ICU?

Kent Bottles

Grand Rounds by tradition has to include at least one Sir William Osler quotation. So let's get the quote from the ideal 20th century physician out of the way:  "The good physician treats the disease, but the great physician treats the patient."

The physician/patient relationship is at the center of the health care enterprise.  Hospitals, insurance plans, third-party payers, government entities, and others are important, but they are really adjuncts that support, finance, and facilitate the key relationship between those who are sick and those who care for them.

This key relationship is in trouble, and patients and providers alike are troubled by participating in healthcare systems that just don't seem to work so well anymore.

The medical blogosphere is a great place to take the temperature and blood pressure of this relationship.


Perhaps the most dramatic development in the evolving doctor/patient relationship was the English newspaper expose that physicians in New Orleans were allegedly "putting down patients" after the hurricane hit. My editor's pick for the blog of the week is from Respectful Insolence for "Active Euthanasia in New Orleans:  An Urban Legend in the Making?". This blogger supplies links to the original newspaper article and explains why he is skeptical about the reporting.  The idea of doctors practicing euthanasia is controversial because it gets to the special nature of the therapeutic relationship:  the need for transparency; the need for trust between the physician and the patient; and the need for patients and doctors to understand what each ideally should do in the relationship.


Not quite as disturbing, but still an indication that our key relationship is not healthy was the Wall Street Journal article that documented physicians suing their patients for negative patient feedback on the Internet.  Techies and patient advocates could not believe that physicians were so thin-skinned, and physicians worried about their professional reputations http://www.soundpractice.net/article.cfm?id=201.


KevinMD on Tuesday, September 13, 2005 also linked to a Wall Street Journal article that reveals that more than half of Americans say they have ignored treatment advice from a physician on the grounds that it was too aggressive or unnecessary.  Those surveyed thought that doctors were too aggressive because of concerns about malpractice, desire to earn more money, and desire to meet patient demands: http://www.kevinmd.com/blog/2005/09/more-than-half-of-u.html.


The doulicia blog about the contrasting coverage in the Wall Street Journal and the New York Times of guests, family, friends, and coaches attending births nicely highlights many of the tensions in the doctor/patient relationship: http://doulicia.blogspot.com/2005/09/guests-at-birth-part-i.html.


Oasis of Sanity, in the finest tradition of empowered patients, shared some detailed, hard-won knowledge about the fine points of thyroid replacement therapy in a blog titled "On combined T4/T3 therapy, or feeling better on thyroid Meds"  I thought she sounded like she knew of what she speaks and I liked the way she treated the endocrine expert as a partner who needed the perspective of a patient to get at the whole truth.


Another patient perspective highlights all of the tensions inherent in the doctor/patient relationship.  What happens when a physician dismisses a patient?  Find out, from the patient point of view, at http://goodbyedp.blogspot.com/


Elisa at HealthyConcerns.com submits a blog that describes how patients feel when they try to connect the dots between what they are feeling and what they should do medically at http://workerbees.typepad.com/healthyconcerns/2005/09/healthy_story_w_1.html


The Cheerful Oncologist also discusses the tension involved in the relationship when a patient wants to know why his tumor was not diagnosed sooner: http://thecheerfuloncologist.blogsome.com/2005/09/12/delay-in-diagnosis/


The Haversian Canal in an open letter to a prostate patient nicely summarizes how to be an empowered patient who does their own research and takes responsibility for making their own decisions: http://nielsolson.us/archives/2005/09/advice_to_colln.php


The Genetics and Public Health Blog reports on a source of tension for physicians that many patients probably don't appreciate:  disruptive technologies that change the way medicine should be practiced.  Genetic susceptibility tests will change the medical paradigm from diagnose and treat to predict and prevent, but this blog states that some physicians feel too overwhelmed to learn new tricks and are not mastering these new tests:  http://www.aboutweblogs.com/genetics/item/1774


Script, the 4th year medical student I podcast interviewed a while ago, blogs about how frustrating it is to be on the cardiology consult service seeing patients with poor prognoses: "These things make us feel better, but they don't make his broken heart unbroken." http://script.blogs.com/script/2005/09/cardiology.html


Patients are reminded by Insureblog that employee assistance programs can provide a lot of help:  http://insureblog.blogspot.com/2005/09/like-bridge-over-troubled-waters.html


How can podcast crazy sites like soundpractice.net not get excited about Clinical Cases and Images who teach both patients and providers how to utilize text-to-speech programs that can take medical texts and convert them to audio that can be listened to in the car: http://casesblog.blogspot.com/2005/09/text-to-speech-programs-and-continuous.html


The Krafty Librarian has compiled a list of medical podcasts that could help patient and doctor alike in their quest to keep up with all the knowledge they both need:  http://kraftylibrarian.blogspot.com/2005/09/medical-podcasts.html


The doctor/patient relationship is not a friendship and not a colleague to colleague work relationship.  It is a special therapeutic relationship with special rules and boundaries.  Maria in http://www.intueri.org/?p=1493 draws a boundary at an older male patient flirting with her.


Bioethics Discussion Blog tackles whether doctors talking about themselves with their patients is a relationship boundary violation or a therapeutic tool to help patients cope:  http://bioethicsdiscussion.blogspot.com/2005/09/doctors-talking-to-patients-about.html


Talk about boundary violations in a therapeutic relationship, check out the New York Times article this Sunday which starts with the following: "Susan Mae Polk was 15 when she visited a therapist, 16 when they had sex, 25 when they married, and 44 when she killed him." (A California Murder Case Raises Troubling Issues, September 18, 2005, A18). (http://www.nytimes.com/2005/09/18/national/18polk.html)


Surveys have revealed that the American public thinks that physicians worry too much about money.  Medrants links to an article about financial interests of doctors and concludes: "money talks, and many listen.  You deserve to be skeptical of physicians, lawyers, and even car salesmen":  http://medrants.com/archives/2005/09/16/ways-physicians-become-financially-unethical/


The Health Business Blog chimes in with a piece about how to decrease waiting times that bedevil doctor and patient alike: http://www.mppllc.com/pages/2005/09/how-to-make-health-care-more.html.


The doctor and patient both find themselves trapped in a dysfunctional non-system.  The always modest Matthew Holt assures me that this blog will make clear what is wrong with this system:  http://matthewholt.typepad.com/the_health_care_blog/2005/09/tech_jd_klienke.html
So in the end what do patients want?  I think they want autonomy, kindness, competence, and respect.  What do physicians want? Autonomy, respect, being able to make a living, and the time to connect with their patients.

It is as true today as it was in 1927 when Francis Peabody wrote:

"The good physician knows his patients through and through, and his knowledge is bought dearly. Time, sympathy and understanding must be lavishly dispensed, but the reward is to be found in that personal bond which forms the greatest satisfaction of the practice of medicine.  One of the essential qualities of the clinician is interest in humanity, for the secret of the care of the patient is in caring for the patient."


Next week's Grand Rounds will be hosted by Dr. Jacob Reider, founder of Medlogs.com and www.docnotes.com.

Post Your Comments modified: Mon, Sep 19, 2005