“It’s all about relationships.”
That’s what a mentor told me during my medical training. Every day, as a pediatrician, I realize how true this is.
With the recent emergence and increasing popularity of virtual doctor visits due to convenience and lower costs, it is necessary to examine the nature of the interaction between doctor and patient.
As patients, we go to our doctors in our most vulnerable states. We want them to tell us what we want to hear — that nothing is wrong and our deepest fears are unsubstantiated. Sometimes that happens, and unfortunately, sometimes it doesn’t.
In a new study in Pediatrics, researchers from the University of Colorado and the Centers for Disease Control and Prevention found that approximately one in five pediatricians will discontinue care with a family if they refuse to vaccinate their children. These doctors make this choice despite clinical guidelines from the American Academy of Pediatrics to not dismiss from their practices families who decide not to vaccinate their children. These guidelines were reaffirmed in 2013, and the American Academy of Pediatrics continues to endorse universal immunization of children. This study highlights the complex dynamics of parental vaccine refusal and pediatricians’ responses.
In medicine, a guiding principle is to “first, do no harm.” Even when you disagree with a patient over his or her practices, behaviors and beliefs, you still must do your best to build these relationships and “first do no harm.”
Other areas of disagreement may include refusal of blood transfusions due to religious reasons and withdrawing life support. It is important to consider whether it would be best for a patient to find another doctor. This issue is an area that requires further study.
As patients, we go to our doctors in our most vulnerable states. We want them to tell us what we want to hear.
The Doctor-Patient Relationship, 2015 Version
Over time, I have started to think of the doctor-patient relationship as one that also involves extended family members that can —and often do — cause dysfunction. Partnering with these sometimes-dysfunctional aunts, uncles, and in-laws are the Internet, media, insurance companies and the lack of time.
As a child, I watched the relationship between my grandfather and his doctor, who treated him for amyotrophic lateral sclerosis (ALS). This experience was at the core of my own calling into medicine. I wonder what his journey would have looked like today.
My grandfather did not want to be kept alive by extraordinary measures, and this was discussed with his longtime doctor and our family. His wishes were honored, and his doctor was at the center of the experience for everyone.
At the core of my grandfather’s relationship with his doctor was trust. Trust develops over time, listening and shared experiences. It is fundamental to every relationship, including the ones between doctors, patients, and families. This was in the 1980s, and perhaps I was young and naïve. However, it did not seem as complicated as what happens in medicine today.
The Internet is another extended family member in the doctor-patient relationship, acting as an acknowledged or unacknowledged guest. In my clinics, many families come to visits after researching symptoms of autism, as well as treatments. They also have an idea of what autism is, purely based on characters they have seen in movies such as Rain Man or on television, including Max on NBC’s now-discontinued show, Parenthood.
I go online to diagnose for myself, and I went to medical school. If I have a symptom, I look it up online and have an idea of a plan before I go to my own doctor. Sometimes my doctor will agree, and sometimes not. I trust her judgment, and this trust has been built with time. She is also open to discussion.
Reputable medical sites such as the Centers for Disease Control and Prevention, Mayo Clinic and the National Institutes of Health are fine sources of information when we have a question, but they offer just that: information. Sites do not have the ability to discern, observe and assimilate all of the facts — especially individual considerations for the patient. Sites cannot develop and sustain relationships no matter how often we visit them.
As so many are discovering with the ongoing discussions about the Affordable Care Act, insurance companies have also become critical to doctor-patient relationships.
Each day I see children and their families and recommend treatment. We then talk about checking with their insurance company to see if the recommended treatment is covered. This is a particular challenge for families with children who have developmental disorders such as autism.
Negotiating with the insurance company is another full-time job for many families, in addition to caring for their children and supporting their families.
Time is another party to the doctor-patient relationship. Recently in the United Kingdom, family doctors demanded doubling of their patient visit times — to 15 minutes. In the United States, insurers will not pay for a visit if it is less than 15 minutes. Doctors want to spend time with their patients and families, but they also have to make a living.
Medicine is all about relationships, regardless of the age of the patient, parent or caregiver. And these are relationships we choose and the relatives whose behavior we cannot choose or control.
Doctor-patient relationships are becoming more complicated, and we need to consider and advocate for how we protect them.
We need more time with our patients and families, and we also need improved reimbursement from insurance programs so we can spend time with them. Equally important, improved reimbursements also allow us to develop programs to support patients and families in the journeys they did not choose.