From the desk of the EMD: The physician-patient relationship: going, going, gone?

September 4, 2018

The physician-patient relationship has long been the cornerstone of the practice of medicine. I would imagine that most allergists would say that it is the connection they have with their patients, parents and caregivers that brings them the most joy in the practice of medicine. The American Medical Association (AMA) Code for Medical Ethics on the patient-physician relationship states, “The practice of medicine, and its embodiment in the clinical encounter between a patient and a physician, is fundamentally a moral activity that arises from the imperative to care for patients and to alleviate suffering. The relationship between a patient and a physician is based on trust, which gives rise to physicians’ ethical responsibility to place patients’ welfare above the physician’s own self-interest or obligations to others, to use sound medical judgment on patients’ behalf, and to advocate for their patients’ welfare.”

You will notice that the AMA states “The relationship between a patient and a physician is based on trust…” Whether we like it or not, this trust is eroding and disappearing. That will lead to the loss of the patient-physician relationship. How can I say that? You are probably thinking that the loss of the patient-physician relationship doesn’t apply to me and my patients. All my patients think I am great and have confidence in me. Let me tell you why I think you are wrong. Let’s first look at you, the allergist, and then the patient.

With the pressure to see more and more patients daily due to the reduction in reimbursement, time with each patient decreases. Decreased time alone doesn’t itself mean a deterioration in the patient-physician relationship but it can be if the limited time is not “quality” time. The electronic medical record can act as a barrier between the patient and the physician. When you spend more “face time” with the computer screen than with the patient’s face, it definitely harms your bonding with the patient. The stress and costs of dealing with prior authorizations and step therapy can also put pressure on your association with the patient. You may get some of the blame from the patient when a medication can’t get approved. With more and more allergists becoming employees, the financial interests put on the physician by their employer may put the doctor at odds with the patient. The rise in physician burnout is one of the major reasons that the patient-physician relationship is eroding. The stresses triggering burnout definitely affect how the physician interacts with the patient.

The other side is the patient. We have all had to deal with Dr. Google as the patient brings reams and reams of paper with their diagnosis for us to confirm. No, I don’t believe medicine should go back to the “paternalistic” role of physicians, but the “know-it-all” patient won’t work either. We need shared decision-making if we want the optimal relationship between us and our patients. Costs of health care, especially the increase in deductibles and co-pays, may interfere with relations with the physician. Patients may have unrealistic expectations of results from their medical care which can put a strain on the physician. We all have had to deal with patients who won’t make lifestyle changes that would improve their medical problems. I’m sure you have seen that asthma patient who won’t quit smoking.

With all these problems eroding our rapport with patients, what can we do? How do we get trust back? Here are a few suggestions: Improve your communication and listening skills; develop more empathy with the patient, make eye contact with the patient and sit down while taking a history, and learn to do shared decision-making. The College is developing more and more shared decision-making toolkits that are available on the practice management section of our website. Allergen immunotherapy, atopic dermatitis and severe asthma are available now, and soon we will have pediatric asthma. With understanding the numerous sources of concern and starting with these ways to improve the patient-physician relationship, trust can begin to be restored.

Michael Blaiss, MD, FACAAI, Executive Medical Director