- Non-physician patients may not understand their complex medical conditions or know what questions to ask.
- Patients need a two-way dialogue with their physicians to understand and make important healthcare decisions.
- Relationship-driven-medicine promotes dialogue and brings the patient to the center of the medical encounter.
By Mariam Rahmani, M.D.
Jane’s primary care physician informed her at an annual checkup that she had a heart murmur requiring further evaluation by a specialist. Jane was referred to an interventional cardiologist who said she had aortic stenosis and that her aortic valve needed to be repaired or replaced. He informed her that the cardiology team would review her case and someone would get back to her.
A week later, a cardiology nurse called Jane and said, “You are a candidate for either a non-operative transcatheter aortic valve repair (TAVR) or traditional open-heart valve replacement surgery.” Not knowing anything about either option, Jane asked, “How do I decide?” The nurse responded, “I can’t tell you. You are a candidate for either procedure. You decide.”
Feeling overwhelmed by the absence of any guidance, Jane sought a second opinion at a prestigious hospital in a distant city where the cardiology specialists told her, “You are not a candidate for TAVR. What you do need is open-heart surgery.” However, Jane’s husband, John, a retired physician, made inquiries about a complicating factor in Jane’s medical history, a rare type of stroke she had experienced five years earlier, which the cardiology team did not address. Jane felt totally confused, scared, and lost, and had no idea about whom to turn.
Jane’s experience isn’t unique. Both approaches to responding to patients feel like being lost in a swamp: one has no sense of which direction to turn to survive.
One of the swamps in which Jane found herself could be called, “You Decide.” This is a common occurrence in the “patient-as-consumer” approach to medical care. Patient choice is an admirable value but one often recurring problem is that many patients are not given enough information to be able to make such an important choice. The pronouncement, “You decide,” is an unhelpful statement that may preclude any relevant and necessary discussions of variables relevant to each unique patient.
The other confounding swamp is that of “trust the expert.” This approach is based upon a hierarchical physician-patient relationship. However, it may come at the cost of a mutual understanding of the patient’s illness and patient autonomy.
Whether one finds oneself in the “you-decide-swamp” or the “trust-the-expert-swamp,” the interaction with the health care system is mostly about the procedure, never about the patient. Often it feels like the patient barely exists in medicine today. Yes, the patient is the subject in the imaging, or referred to in the electronic medical record; but is certainly not the person in the room. Has anyone noticed how rarely the physician even touches the patient anymore? There is an all-encompassing disconnectedness in medicine today compromising every aspect of the process.
Jane’s husband, John the retired physician immersed himself in the relevant medical literature involving aortic stenosis and stroke. He attempted to gauge the potential complications of both approaches within the context of her two medical conditions. Doing so was an arduous process that took two months of reading every night into the early morning hours.
Eventually, John contacted a friend who held an important position at the hospital where the original interventional cardiologist from the “you decide” swamp worked. The friend listened to their concerns and arranged for them to meet with the original interventional cardiologist again.
To their happy surprise, this time the interventional cardiologist met with them for an hour, explaining the advantages and disadvantages of each procedure as it applied to Jane’s medical conditions. At the end of the meeting, Jane and John were certain the TAVR procedure was the best choice for her. John was in tears by the end of the appointment.
How Can a Patient Be Sure?
Nobody today can be certain they or their loved ones are receiving good medical care — except physicians — who have a chance, not because of being physicians, but because physicians have the background and experience to read and understand the literature, ask appropriate questions, listen critically, and integrate the relevant factors to come to an informed decision.
The disconnect in our current system—between physicians and patients, between physicians and families, and between physicians and other physicians—is pervasive. All too often this is because the personhood of the patient is effectively never a consideration because the person of the patient does not exist in this system. The current state of affairs has been further exacerbated by the widespread adoption of the electronic medical record, which does not promote relationships and can be a false substitute for them.
As a result, who but a physician-patient has any chance to follow the path described here?
Perhaps a beginning toward a new relationship-driven-medicine model would be finding unmistakable ways to re-emphasize the importance of primary care and rediscover the value of the physician-patient relationship. The medical dialogue in the form of a two-way conversation needs to come back to the center, back to the person and family, instead of being isolated without recourse at the periphery.
Some possible strategies for relationship-driven medicine include:
- Increased emphasis on family-centered care for residency and fellowship training in all specialties by the Accreditation Council of Graduate Medical Education.
- Patient evaluation of the quality of the physician-patient relationship must be required for the maintenance of board certification.
- Advocacy with health insurance companies for competitive reimbursement for high-quality medical care provided to patients.
The medical system might then focus on the physician-patient relationship, the physician-family relationship, and the necessity of authentic cooperation between physicians. Patient care should develop within a relationship system in which patients and physicians engage in real interactions for the care of each patient.
Mariam Rahmani, M.D., is a member of the Research Committee at the Group for the Advancement of Psychiatry.
de Zulueta P. Touch matters: COVID-19, physical examination, and 21st century general practice. Br J Gen Pract. 2020 Nov 26;70(701):594-595. doi: 10.3399/bjgp20X713705. PMID: 33243905; PMCID: PMC7707044.
Manta CJ, Ortiz J, Moulton BW, Sonnad SS. From the Patient Perspective, Consent Forms Fall Short of Providing Information to Guide Decision Making. J Patient Saf. 2021 Apr 1;17(3):e149-e154. doi: 10.1097/PTS.0000000000000310. PMID: 27490160; PMCID: PMC5290300.
Wellbery C. The importance of touch. Am Fam Physician. 2007 May 15;75(10):1482. PMID: 17555140.