Is the doctor-patient relationship contributing to physician burnout?

The Doctor-Patient Relationship is over 2500 years old

Much has changed since Hippocrates placed his hands on his first patient. Medical innovation, technological advances and the organization of professional standards have reshaped the practice of medicine. What hasn’t changed fundamentally is the relationship between healer and the sick but other forces are at play, straining this relationship. Most focus has been on the patient side of the equation but as physicians begin to feel the effects of these strains and as the relationship unravels it manifests as physician burnout which now by some estimates affect as much as half physicians in the U.S.

Classic Relationship between Doctor and Patient

Numerous scholars have written about the classic relationship and is still controversial today. Pamela Wibble wrote a wonderful cover story on Medscape about the Love/Hate relationship with doctors illustrating some potential sources for the mistrust in the relationship such as money, improper expectations, and violation of trust. She argues that a fracturing of the relationship comes when intermediaries place themselves between the two and a potential solution would be to reestablish a fiduciary relationship with the patient. This love/hate relationship even goes further back to the 15th century where Moliere created numerous satirical comedies of the nature of the relationship arguing in many cases that physicians given their vast knowledge of the medical science were no more effective than an imbecile pretending to imitate one. Nicole Mak demonstrates through her analysis of Moliere’s plays that physicians have a greater responsibility to the “shift medical doctrine to the whole-person” as opposed to overpowering the patient with “possession of knowledge” and technical procedures¹.

The Core of Any Relationship

Despite the move from the classical role of a physician as dominating figure giving advice to an obedient patient to the modern humanistic “Patient-centered” model² of current western medical doctrine, the basis of the relationship hasn’t changed. What is a relationship? I struggled with this concept until I began to think of it in the context of human interactions. A relationship according to dictionary.com is the state of being connected.

Connectedness takes on many forms:

Blood/Relative
Love/Marriage
Bond/Friendship
Alliance/Organized societies
Contract/Services

To keep these connections complete every relationship has needs to be met. In each of the above examples, conditions must be met to keep the relationship intact. Money is required for the transactional relationship between store and customer and love is required for marriage. In each case, both parties are sensitive to needs of the other. The doctor-patient relationship in many ways looks like both a sales transaction and a marriage. We train to have the highest of professional standards but at the core of the doctor-patient relationship is intimacy. Looking at this from the perspective of the patient, what other relationship carries enough trust to allow another person touch them let alone perform a procedure on them? As with all relationships, the connection is mutually beneficial.

Major elements of the Doctor-Patient relationship

Patients have physical, biological and psychological needs to have a healthy life. They seek out physicians to prevent or treat illness in exchange for payment. Physicians needs on the surface seem straightforward but are more complex. Beyond the payment for services rendered, physicians need performance feedback to legitimize their actions and affirm their self-esteem. As a direct result, physicians experience a sense of well-being. This feedback loop grows over time and becomes reinforced improving the life of both.

When does the relationship go wrong?

In the purest sense, a simple relationship can have numerous obstacles to place a strain on it and conflict can occur when two entities try to assert their needs. This results in a power struggle. Unacknowledged power festers and destroys relationships. The imbalance occurs when one person has knowledge, resources or some advantage over the other. In the case of the doctor-patient relationship, there are three stages described by Szasz³:

Parent-infant model or Activity-passivity
Parent-child model or Guidance co-operation
Adult-Adult model or Mutual participation

The power shifts depending on where the relationship exists on the spectrum. The top benefitting the physician and the bottom benefiting the patient. In The evolution of the doctor-patient relationship, Kaba argues the power struggle has evolved depending on the historical time frame and context within society. Before the age of enlightenment healers and priests dominated those who sought help. Once Greek enlightenment and the age of reason took hold, Hippocrates shifted the balance by creating a”Bill of rights” for patients and creating medical ethics to the Guidance co-operation state. The power shifted back and forth depending on the time period, region and stability of the society. According to Kaba, patients have had historically little power except for the Renaissance where there were very few doctors with limited skills who were in service to a very small wealthy class.

The rise of the Hospital

The next shift in the relationship occurred with the emergence of the 18th-century hospital which functioned to serve the underprivileged and the poor. This placed the physician back at the forefront of the relationship to the Activity-passivity role. Having an unlimited pool of people to conduct experimentation, medical knowledge, especially in microbiology, grew rapidly. Suddenly physicians began to discover the underlying causes of symptoms and disease. This knowledge bestowed upon physicians a magic power into the secrets of the human body. René Laennec invented the stethoscope in 1817 and continues to be Merlin’s wand of the profession. This power did not come without consequence as the Hospital became the first entity of many to integrate itself into this relationship.

Power tends to corrupt

Western medicine spread rapidly over the next 150 years throughout Europe and into the U.S. Earlier on many doctors received their education in Europe or through apprenticeship. As medical schools multiplied the training shifted to local medical schools. Since formal licensure didn’t fully exist throughout the country until the 19th century, physician competed with each other but also other types of healers, herbalists, osteopaths, and charlatans. Not liking this competition, physicians at major universities enlisted the help of the government for the sake of the greater good of society and their pocketbooks. In 1910, the Flexner Report fit the ticket by setting strict standards for medical training including the current standard 4-year program⁴. As a result, 50 medical schools were closed, all apprenticeship programs ended and all the competition ended. The unholy alliance became the second entity to integrate itself into the relationship and it all resulted from greed.

Assurance of Insurance

Prior to 1900 the average physician practiced in a city no larger than 2500. As the population grew and the competition was kept at bay, the need for the services of physicians continued to grow. Large corporations began to realize the need to keep their employees healthy in order to keep a productive workforce. Montgomery Ward was one such company who decided to offer insurance to their employees⁴. Insurance was already offered in other industries to mitigate any catastrophic losses such as from train accidents so it made sense to pool the risk in medicine. This worked well until the great depression created a large poor population that lacked resources to pay for services and the payment by chickens and eggs era came to light. Consequently, insurance evolved with the help of the AMA and Hospital Association to include routine care to help pay for this shortfall. Hence the third entity was born to again integrate itself into the relationship.

Lets Party with the Third Party

As the insurance companies grew they looked for other opportunities to improve their bottom line. Blue Cross like the universities before them sought the aid of the federal government by requesting tax exemption in exchange for providing affordable health insurance to the public⁴. Although this seemed like a great idea ultimately it resulted in ever-increasing premiums due to “community risk” pooling of the premiums mandated by the government. Instead of charging individuals based upon their independent risk factors similar to car or life insurance, Blue Cross had to pool the risk thereby increasing the rates of the healthy in exchange for decreasing the rates of the sick. This may sound altruistic but it ultimately resulted in a failed business model because there were not enough healthy people paying into the system to offset the sick people. The fourth entity, the government, enters into the already crowded relationship.

Medicare and Medicaid

As a result of the failed business model, the private health insurance companies were about to go bankrupt and take down the entire insurance industry with them. Again they sought out the help of the government and the Birth of Medicare and Medicaid became federal law. Now the sickest and soon to be the largest portion of the population will be the responsibility of the ultimate third party, the federal government. The final entity entered the equation of the relationship which like any government contract will come with an endless string of qualifications and regulations.

A Strained Relationship

Up to this period, physicians enjoyed many benefits and had lots of power. They had a highly regulated and monopolistic industry with a very high hurdle for entry to limit competition. As a result, the average physician enjoyed a sizable income multiples beyond that of a regular worker. Physician were esteemed members of the community and often received praise both in the private and public sectors. Despite government regulation, they also enjoyed relative autonomy to practice medicine with state medical boards, medical staffs in hospitals and practices run by physicians. At the same time, a new trend toward humanistic medicine began to grown and thinkers like Freud, Balint, Szasz, and Hollender which would swing the pendulum the other direction. They advocated for the patient, contending that physician must not only treat the biological aspects of the relationship but also the psychological. This model looked at the human side of the relationship equation and proposed that physician and patient have a relationship of “mutual participation.” Through their work, the patient-centered model of care emerged. This ultimately has pushed the needs of the patient in favor of the needs of the physician resulting in another power conflict.

Where is the relationship today?

All relationships require a historical and societal context. The medicine of today looks less like the idealized relationship depicted by Norman Rockwell or other editorials about the country doctor that made house calls, and more like an industrial revolution like that of Upton Sinclair in the Jungle. Despite the patient center model, patients today have no more power or choice than they did 10,000 years ago unless they have privileged access such as a member of Congress or a close family member who happens to be a doctor. Instead, they face an ever-confusing sea of bureaucracy with their medical insurance changing year after year with denial of coverage the norm instead of the exception. When they the do make an appointment they often have to wait a very long time to see their physician if they have one or will most likely see a PA or NP that they have never met before and will never see again. I will read an article from time to time proclaiming the “relationship” is alive and well. Although true, it seems more and more less frequent.

Physicians

We, as physicians wield a rather large amount of power over our patients despite the efforts of scholars, non-practicing clinicians, government officials and other interests. I believe Hippocrates:

‘‘The regimen I adopt shall be for the benefit of my patients according to my ability and judgment, and not for their hurt or for wrong.Whatsoever house I enter, there will I go for the benefit of the sick, refraining from all wrongdoing or corruption, and especially from any seduction, of male or female, of bond free. Whatsoever things I see or hear concerning the life of men, in my attendance on the sick or even apart there from, which ought not be noised abroad, I will keep silence thereon, counting such things to be as sacred secrets.’’

He knew this power was corruptible and if not used correctly could result in a disastrous outcome not only for our patient but also for ourselves. Since his wisdom has gone on deaf ears, we have created more layers of complexity to a relationship that was already complex. Although we still command a good income it comes at a great cost. We have lost our ability to enter a fiduciary relationship with our patient. We have become a servant of the third payer system who dictates our practices and treatments. Government regulation and litigation increased the administrative burden to the extent that the average physician works an extra hour a day to complete electronic medical charts⁵. And finally the key to any relationship, trust continues to erode as countless patients seek out more meaningful intimate relationships with non-physician in hopes to restore their health. Once this intimacy is gone and replaced with mechanical tasks our relationship erodes and suddenly the work we do gets less meaningful, without purpose and eventually gets to the point of burnout.

Solutions

Patients are patients and have always been patients. They suffer an illness and seek help to solve their problems. This will never change. Moral Hazzard will always exist in a free society as one of the unfortunate unintended consequences of freedom. If not smoking, guns, alcohol, risky behaviors, then something else will result in a medical emergency which will be needed to help them correct. If we cannot directly change the winds then perhaps we can change ourselves. I have still yet to meet a baby boomer or greatest generation doctor who didn’t absolutely love to practice medicine. I am not entirely sure why this is the case but if I were to guess, I suspect it had to do with the intimacy they had with their patients and the relationship they were able to foster. Today with the time constraints, the administrative requirements, call duties, the patient load or distractions that didn’t exist 20-30 years ago, fostering an intimate relationship with a patient can be difficult if not impossible. Limiting these relations in lieu of the other busy work only creates greater resentment and ultimately for unhappy work life. I think by looking inward and reexamine our lives and priorities we can learn to set boundaries for ourselves and for outside influences trying to control our time and efforts. Once we do this we can begin to heal the real core of our power as physicians which is the Doctor-Patient Relationship.

“People don’t care how much you know until they know how much you care”

― Theodore Roosevelt

The evolution of the doctor-patient relationshipKaba, R. et al.
International Journal of Surgery , Volume 5 , Issue 1 , 57 – 65
America’s love/hate relationship with doctors. Wible, P. Medscape Feb 2018 pp 10-11.
Resgressing or progressing: what next for the doctor-patient relationship. Harrison, N. The Lancet Vol 6 March 2018 pp 178-180
Physician Culture and the Identity: the protrait of Medicine in Moliere. Mak, Nicole. Intima Spring 2015, pp. 1-12.
The rise and fall of the Doctor-Patient Relationship. Cole, T. Houston History of Medicine Lectures. 1-4-2012.
Patients and Doctors- The evolution of a relationship. Troug, R. New England Journal of Medicine. 366;7 Feb 16, 2012.
The impact of EHR usage on patient satisfaction. Marmor,R. et. al. DOI Vol 9 1/ 2018 pp. 11-13
The Doctor-Patient relationship is alive and well. Ofri, D. The New York Times July 13, 2016.
A country doctor can’t forget his 40 years of house calls. Greene, B. WSJ Feb. 9,2018.