doctor, patient, relationship, HMO, PPO, dr dale peterson

Toward a Healthy Doctor-Patient Relationship

Toward a Healthy Doctor-Patient Relationship

© 2010 Dr. Dale Peterson

The headline of a medical article caught my attention recently. It read, “Smile as you steal my patient.” The words reminded me of those of a representative of a major insurer in the Oklahoma City area many years ago. “We now control,” he proudly proclaimed, “200,000 lives.”

Webster’s Ninth New Collegiate Dictionary defines a doctor as “one skilled or specializing in healing arts” and a patient as “an individual awaiting or under medical care and treatment.” In its purest sense the doctor-patient relationship is that of one person facing a health challenge seeking the assistance of another in overcoming that challenge. There is nothing in that relationship that dictates that the individual skilled in healing arts is superior to the person seeking healing, save that he or she is more knowledgeable in the treatment of disease.

The patient may, in fact, be of greater social standing than the physician. The patient may be more accomplished in many areas. The patient may possess greater wealth than the physician. The patient may even have a greater capacity for caring and compassion than the physician. It is therefore ironic that the doctor-patient relationship is, in many cases, characterized by that of a master and slave, of a superior to an inferior.

How can someone be “stolen” unless he or she is viewed as property rather than as a unique and free individual? How can someone control another person’s life unless that person is considered a slave or servant of the someone in control? While the view of patient as slave is not overtly expressed, statements such as those cited above unveil the mind-set of many physicians and virtually all insurers today.

Such attitudes are not new to the profession, but I believe that the intrusion of governmental agencies and insurance companies into the once sacrosanct physician-patient relationship has intensified them. When I entered medicine practices were built slowly through involvement in the community, a simple yellow-pages listing, and providing care in a manner that encouraged people to not only return personally, but to refer others.

All that changed with the advent of insurance products called PPOs (preferred provider organizations) and HMOs (health maintenance organizations). People were given financial incentives to choose the products. In exchange for a lower premium or greater benefits individuals were required to choose a physician, not on the basis of a pre-existing relationship or recommendation from a friend or family member, but from a list of “providers” who had agreed to discount their services.

I shall never forget my first shake-down by an insurance company. It was a very humbling experience. I was finishing a busy morning in my office when a woman in a business suit approached me. “I’m from Major Insurer,” she announced, “and I’m offering you the opportunity to become one of our preferred providers. There’s a $300 application fee, and all we ask is a 10% discount from your current fee schedule.”

“Why would I be interested in doing that,” I asked incredulously?

“Because if you don’t join our network we won’t let your patients see you any longer,” she replied with all the confidence of a mobster collecting protection money.

In that instant my world changed. No longer would my practice be made up solely of people with whom I had developed a relationship based upon mutual trust and respect. Moving forward it would increasingly be characterized by resentful, suspicious individuals who were coming to see me only because I was a provider whose name was on a list that did not contain the name of the physician they had previously come to know and trust.

Ironically, the “cost-saving” strategy of directing people to providers on the basis of their association with a particular hospital or willingness to discount their services resulted in a much higher cost of medical care. If an established patient, one with whom I had developed a strong relationship, presented with a history of headaches I could, on the basis of my office evaluation, conclude that it was a migraine and proceed to explain how to manage and prevent them. If someone who was seeing me solely because I was on an insurer’s provider list presented with a history of headaches, an office evaluation was rarely sufficient. “That’s may be your opinion,” the person would state, “but when are you going to order my MRI?”

Insurance company contracts have far deeper implications than cost containment, however. When an individual purchases medical insurance today there is almost always a clause granting the right of company representatives to view all personal medical records. When physicians sign contract with insurers there is always a clause granting the company the right to review any and all medical records of their insured members at any time and for any reason. Auditing the records for evidence that charges were billed appropriately is a major focus of third-party payors, but their interest does not stop there. Every aspect of the physician-patient encounter – I dare not use the term relationship – comes under scrutiny. Were immunizations brought up to date? Was the medication prescribed appropriate to the situation? Was the patient placed on an aspirin a day? Was a cholesterol-lowering drug ordered? Was bone-density checked and were drugs prescribed if indicated?

Seeing patients who have entered into voluntary servitude to governmental or private insurers engenders a slave master attitude in physicians. Obligating themselves to treat those patients as the insurer dictates only serves to solidify this viewpoint. Although this mind-set generally goes unrecognized, it is, nonetheless the basis upon which many of today’s physician-patient relationships are built.

This is a major reason I refuse to accept third-party payment for my services. I have lost many potential patients over the last decade because I was “not on their insurance.” Despite the loss of revenue, dealing directly with people in a confidential one-on-one manner has been liberating. It has given me an opportunity to return to the quality of relationships I enjoyed in the early years of my traditional medical practice. It has given me the ability to view those seeking my advice not as property, but as people.

I believe the ideal physician-patient relationship is one that recognizes that both individuals on seeking the path to optimum wellness. One may be farther along on the journey, but neither has arrived at the destination. They are fellow travelers, eager to offer each other advice and comfort. Some of my best teachers have been patients who challenged me to investigate a new theory of disease, a particular nutritional supplement, or a novel medical procedure. I am as much indebted to them for assisting me along my health journey as they are to me for the counsel I provided.

That kind of doctor-patient relationship is not only healthy; it can be therapeutic as well. I can recall many patient visits in which I had nothing to offer but a listening ear and yet improvement in the patient’s condition ensued. The presence of a trusted friend and confidant can, at times, be the catalyst needed for recovery.

Medical insurance and healthy doctor-patient relationships are not mutually exclusive. They can and often do coexist. Be sensitive, however, to the possibility that a master-slave relationship with your doctor exists and, if it does, be willing to terminate the unhealthy affiliation in favor of one that is nourishing and offers mutual growth.