Tuesday, October 30, 2012

Flaws in the patient-doctor relationship

More excellent insight from John Wennberg's Tracking Medicine, this time on the patient-doctor relationship:
Social scientists had long recognized that the “exchange relationship” between the physician and the patient was radically different from the exchange relationship that determines the demand for other goods and services in most markets. The doctor-patient relationship is different because of the asymmetry of information. The patient, as a layman, does not know what he or she truly needs; it is the physician who knows the nature of the patient’s illness and can select the right treatment. For these reasons, many social scientists thought it was rational for patients to do something they would not dream of doing in most markets—that is, to delegate decision making to the seller of services, the physician, who by virtue of his special knowledge and skill, could act as their “rational agent” in health care purchasing decisions. 
From the patient’s point of view, the agency model was believed to be rational on the basis of several assumptions. First, it was assumed that clinical decision making is grounded in medical science; physicians have evidence-based knowledge to diagnose illness accurately and estimate the risks and benefits for the treatments they prescribe. Second, physicians make accurate judgments concerning the treatments patients want: they choose the treatment the individual patient would prefer, if only they were themselves physicians, and therefore knew the facts and better understood their own “true” wants and needs. This assumption is implicit when a patient says to his or her physician, “What would you do if you were me?” Third, the ethics of professionalism protects the trust that is the basis for the patient’s willingness to delegate decision making to the physician. Despite the fact that the physician benefits financially from higher utilization of his services, professional ethics ensure that he or she will choose what is best for the patient. Finally, egregious behavior by the few unethical physicians who induce patient demand for self-serving motives is detected and controlled through utilization review and other methods the profession adopts to discipline “outlier” behavior.
It seems that all four assumptions are flawed.

1) Medical science is evidence-based, of course, but that evidence is notoriously complex, and oftentimes deeply flawed.
2) Physician-patient communication also has a reputation for being quite poor, with overwhelmed doctors often not having the time to properly discuss options with patients.
3) Professional ethics is probably a fundamentally flawed concept.  I would argue that the concept is important in physician training and education on a micro-level, but that the healthcare system is unwise to rely on this concept on a macro-level scale.
4) And most evidence seems to indicate that our utilization review system is not working.

All that being said, I'm at a loss for solutions on how to change the nature of the patient-doctor relationship.

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