The relationship between physicians and their patients is often thought of as the basis of the practice of medicine.
But as healthcare becomes more corporatized, expensive and inaccessible, some physicians have observed a shift from what was once a relationship based in compassion and care to something more transactional.
Seven physicians recently joined Becker’s to discuss the biggest changes they’ve seen in the physician-patient relationship over the last five to 10 years, and what has driven those changes.
Editor’s note: Responses have been lightly edited for clarity and length:
Raymond Harrison, MD. Internal Medicine Physician Baylor Scott & White Clinic (Copperas Cove, Texas): In the past five to 10 years there has been a big shift from independent practice to consolidated corporate medicine. This has had some advantages such as economy of scale, and consolidation of negotiating power, both legal and financial.
There have been some disadvantages. There is a loss of physician autonomy and a strong emphasis on “customer” satisfaction. I worry this has eroded some of the integrity of medical professionalism. I have seen a decrease in the number of physicians having difficult conversations with difficult patients. Instead, there is pressure to give patients what they want. Many fight these impulses and hold fast to medical professionalism, but when faced with bad metrics and a compromised paycheck, there is a strong temptation to acquiesce.
Physicians do not seem to be held in the same level of esteem as in the past with an increase in distrust of physician knowledge, and in fact, science itself. Rational evidence-based thought seems to have been displaced by ill-informed, sometimes politically driven ideology. It seems to be a classic example of the “Dunning-Kruger effect,” where individuals with no formal medical information read a few Google search results, and believe they are subject-matter experts. This has made practicing good quality medicine challenging at times.
It’s not all gloom and doom, but we have some significant challenges ahead in our profession. I believe it is still a noble and sacred calling, but it needs to be protected by those who practice this millennia old profession.
Richard Hynes, MD. Spine Surgeon (Melbourne, Fla.): The most ominous change that is currently and rapidly evolving is the socialization of healthcare. In that transition, medical practices are literally being forced out of private practice into employment scenarios due to decreasing Medicare/Medicaid payments, while experiencing increasing cost of business liabilities. Bottom line … when most physicians are employed, the patient-physician relationship is powerfully weakened. How?
Advocacy … the age-old, greatest strength in the relationship was/is the physician’s ability and responsibility to advocate on behalf of our patients … it is slipping away quickly and we are losing our ability to protect patients and “do no harm” … sad.
Kenneth Elconcin, MD. Orthopedic Surgeon (Los Angeles): No.1: The time constraint imposed upon the doctor. Most doctors have a 15-minute patient time allotment. No time to really relate to the patient to ask about their family and personal problems in addition to the particular medical problem they’re here to talk about. We really don’t have time to relate to the patient as a person.
No. 2: Documentation of visit. We are required to document each visit for our compensation for the visit. As a result, many doctors spend their entire time on the computer, barely facing the patient. An alternative is to have to dictate in front of the patient. Otherwise, one has to do the dictation after the visit, taking more time away from the doctor.
No. 3: The provider status that doctors are in. Patients are told to see their provider if they have a problem. That could be a physician assistant, or a nurse practitioner or other individual. The doctor is now placed in a position of being just a provider.
Tony Levebvre, MD. Lead Physician at Abbott Northwestern Hospital (Minneapolis, Minn.): Post-pandemic created an era of mistrust of professional healthcare providers with numerous sources of information coexisting that were given equal weight despite bountiful misinformation. This has led to patients and families more frequently being mistrustful of the recommendations that are provided. Our leadership has been so fractured in a wide open display of contentiousness.
Patients now having wide open access to their chart means they often have their results before I walk into the room. They have searched the internet for the meaning of the diagnostic result, looking for both treatment and prognostic information. Upon my arrival they may already have come to a conclusion before we have a chance to talk via any shared-decision making process. Couple this with patients and families using any form of AI and feel as though you are being questioned during the conversation. AI still can’t display true human empathy and patients still need and deserve such, which allows space for us to make the connection.
Overall, the vast majority of physician and patient relationships are still positive. Unfortunately however, many of the above described factors have resulted in both large increases in verbal as well as physical abuse towards healthcare workers. Despite our best efforts, the relationship has been negatively impacted. Patients are sicker and more complicated in our country since they can survive longer with multiple comorbidities. Providers have experienced burnout and the environment of healthcare has become much more tense and intense, mirroring politics.
Marc Shelton, MD. Associate Chief Medical Officer at the University of Missouri Health System (Columbia): The thing that sticks out with me the most is the reduced trust in medicine and pharmaceuticals in general. Several surveys have highlighted this. To me it seemed to start or at least accelerate with the anti-vaxxers, but since seems to now include a more general distrust of medicines, not just vaccines. I believe that non-adherence rates are up, and the attendant problem of bringing as many of our patients as we can up on [guideline-directed medical therapy] seems harder. Patients’ perception about potential adverse reactions to [medications] seems to have grown more than the likelihood that the symptoms are actually due to the meds. I find myself now often having to make statements in the clinic such as, “I’m not asking you to want to take medicines, I am just asking you to realize that you should in order to potentially improve your long-term health.” And, “I would like for you to think about this med as if it were gas. I don’t want to put $3-a-gallon gas in my car either, but if I don’t, it won’t run.”
Easwar Sundaram, MD. President of Texas Institute for Neurological Disorders (Dallas): Unfortunately, the relationship has gone from one of mutual trust and long-term relationships to a transactional and a short-term meeting. The hospitalist concept has totally destroyed continuity of care to one patient seeing several hospitalists in a single stay and everyone follows a different plan and patients are confused. Patients armed with Google search and ChatGPT info now claim that they have the diagnosis and want the treatment they have chosen and not discuss in a collaborative way. The voluminous paperwork, charting requirements, pre-auth and Medicare Advantage rules have created a documentation specialist and taken away the doctor concept!
Finally the word “provider” and not a “doctor” has clearly taken away the most precious thing I earned from medical school and now just “provide” a service and not provide the healing a doctor was supposed to provide!
Sheldon Taub, MD. Gastroenterologist at Jupiter (Fla.) Medical Center: I personally think the physician patient relationship has changed dramatically over the last 10 years. I blame this mostly on electronic medical records, since the doctor may be more focused on the chart and the computer than the patient. Eye contact with the patient is missing! I think you could learn a lot from looking at the patient and paying attention to their physical gestures as they talk to you. Back in the day when I trained, you had to focus on the patient, now you focus on the computer! Unfortunately , with all the distractions in medicine now, and the need to be more efficient because of decreased reimbursement, this has become a necessity. I really don’t think AI will improve this, and possibly it may make it worse. Also, patients present now with computer-driven questions regarding their symptoms. This may have a positive or negative effect on your relationship with them. Because of EMR documentation, and insurance restrictions and demands, the patient doctor visits have shortened. As a result, I think some patients feel less connected with their physicians. Again, I think this will only get worse.
