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The evolution of the doctor-patient relationship

Publication
Article
Medical Economics JournalMedical Economics October 2023
Volume 100
Issue 10

Since the time of the ancient Greek physician and philosopher Hippocrates, who laid down the gold standard of ethics in medicine, the doctor-patient relationship has remained a cornerstone of care. “The process of care between patients and their doctors is one of the most powerful, and at times sacrosanct, of connections we experience as humans,” says Aaron George, D.O., a family medical doctor in Hagerstown, Maryland. “Patients place their lives, their health, their family into the hands of another.”

A century ago, that relationship was inherently personal because many doctors lived in the same communities as their patients and made house calls. What doctors had to offer was basic and contained in their black bags — a stethoscope, needles, dressings, aspirin, iodine — with penicillin, insulin and vitamins still on the brink of discovery. Confidence in a doctor’s competence was not always high, says Jason Chernesky, Ph.D., a medical historian at the Johns Hopkins University School of Medicine in Baltimore.

The world of medical care has since been revolutionized by innumerable scientific and technological breakthroughs and sociocultural influences. Compared with the solo practitioner of old, the doctor-patient relationship now is often backed by team care embedded in the organizational structure of a complex health system where relationships extend well beyond doctors and their patients to other stakeholders — clinicians, administrators, insurers and government regulators — all deeply embedded into every encounter. When George makes his modern house calls, for example, the leather black bag he carries, handed down from his physician uncle, is filled with a growing collection of technology including a continuous glucose monitor, point of care ultrasound, a digital stethoscope and an iPad that connects the care he delivers to Meritus Health, his employer.

The digital era also enables patients to have infinite health information at their fingertips and more options for accessing care. These and other trends are generating wide and serious debate about what the future holds for the doctor-patient relationship, George says — “Is it evolving or eroding?”

Benevolent paternalism

For most of the first half of the 20th century, doctors, mostly White men, were instructed to display an attitude of benevolent paternalism as endorsed by Sir William Osler, often called the father of modern medicine — with “obedience” as the expected patient response, as described by the American Medical Association. The model of doctor as expert decision maker and passive patient endured as America built a new order of health care delivery. From an unregulated cottage industry in the 1920s, medicine moved toward the complex ecosystem it is today over the next decades, an era that ushered in great scientific discovery, growing specialization, care in doctors’ offices and hospitals, a clinical research enterprise and third parties such as insurers and the federal government as active stakeholders.“This large system begins to take over,” Chernesky says, one with layers of hierarchy that supported doctors’ authority.

By the 1950s, effective therapeutics were introduced that eliminated deadly diseases, and notable advances were made in treating cancer and heart disease. Those strides and more led some scholars to characterize the first half of the 20th century as the “Golden Age of Medicine,” with doctors benefiting both reputationally and financially.

But cracks in the doctor-patient relationship also surfaced, including criticisms that advancements in medical technology and drug efficacy allowed doctors to divert attention from their patients to images, and to focus on the disease at the expense of the patient as a person.Physicians had an omniscient authority, able to exert “a kind of medical tyranny” tolerated and even expected by the typical patient, notes Edward Shorter, Ph.D., a social historian of medicine, in his book “Bedside Manners: The Troubled History of Doctors and Patients.” Surveys show patients, for example, were typically not informed of a cancer diagnosis through the 1960s, usurping their prerogatives.

Assertive patients

In 1974, Medical Economics published an article by Donald L. Cooper, M.D., a doctor and medical director of Oklahoma State University’s Health Center, now the Oklahoma State University Center for Health Sciences. Cooper warned readers of a rising generation of assertive patients, unlike those of the past, who would be better informed, expect “all the latest treatments” and shop around for doctors if they were not satisfied — a message not without precedent.

By that time, political and social movements, including those for civil and women’s rights, were shifting authority decisively away from the doctor toward the patient. Public trust in medicine was deteriorating with growing reports of doctors abusing their powers in scandals involving human experimentation, malpractice and conflicts of interest that cast them as unethical and greedy. Two reports by the Institute of Medicine (now the National Academy of Medicine) — “To Err Is Human” in 2000, which explored medical errors and patient safety, and “Crossing the Quality Chasm” in 2001, which called for higher-quality care — shattered any remaining illusions about the infallibility of health care and pointed to patient-centered care as a key to significant future improvements.

Although it has been a guiding principle ever since, patient-centered care remains an elusive goal beset by many challenges. Over recent decades, health care has morphed into a fraught marketplace embattled by the rise of medical consumerism, commercialization and competition, the internet and social media, political polarization, fiscal pressures and widespread disparities. Along the way, the doctor-patient relationship has assumed new transactional aspects that do not always work in its favor. In his book “Strangers at the Bedside,” for example, historian David Rothman, Ph.D., chronicles the fundamental transformation in the doctor-patient relationship, concluding that practitioners no longer know their patients, leaving the latter to experience modern medicine as “powerful and impersonal, a more or less efficient interaction between strangers.”

Questions of trust

Despite the rise of the patients’ rights movement and many advocacy groups, organizations and strategies, historian Nancy Tomes, Ph.D., argues in her 2016 book, “Remaking the American Patient: How Madison Avenue and Modern Medicine Turned Patients into Consumers,” that it is “not at all clear” whether patients are better off today than they were 50 years ago — in part because health care has become an unstoppable juggernaut. The COVID-19 pandemic not only amplified existing tensions in the doctor-patient relationship, but introduced new ones around therapeutic uncertainties, access disruptions and poor, if not deadly, outcomes, particularly for underrepresented groups who have a history of discrimination in health care. An unceasing torrent of medical misinformation fueled rebellion against doctors’ clinical expertise and recommended measures for limiting the spread of the virus, as well as treatments.

Public confidence in medicine, which peaked in the mid-1960s, hit a new low in a 2023 Gallup Poll, with only about 1 in 3 Americans expressing “great or quite a lot” of confidence in the medical system, with other major institutions earning even less. Trust in doctors, although higher, the poll found — with about 2 in 3 Americans expressing confidence, trailing nurses, who ranked first — is still below prepandemic levels.

“That’s tough ground for doctors to be on when patients say, ‘I don’t trust you,’” says Richard Baron, M.D., president and CEO of the ABIM Foundation, which is leading the Building Trust initiative as a national campaign in health care to identify better practices. “Just because people work as doctors, they can’t assume they have trust. In fact, they should assume they don’t and need to earn it.”

Trust — along with empathy, communication and listening, according to research — characterizes a productive doctor-patient relationship. For patients, a consistent relationship with their doctors, particularly in primary care, has been shown to facilitate treatment adherence and improved health outcomes.

But as doctors continue to rank their relationships with patients as the most rewarding part of their job, a 2022 report by Accenture suggests patient loyalty may be a thing of the past. Today, many patients rank a doctor’s knowledge and empathy as less important than access, ease of doing business and digital engagement capabilities available in the practice setting, the report found. Patients are also switching doctors more frequently than before the pandemic.

The future of the doctor-patient relationship

History has shown the doctor-patient relationship is durable and adaptable, but how it may shape-shift in the 21st century due to these trends and others discussed below remains unclear.

Practice challenges

Today, nearly 3 in 4 physicians are employed by hospitals, health systems and corporate entities, a trend that accelerated with the pandemic. At the same time, physicians are either quitting or retiring in record numbers, exacerbating a growing workforce shortage.

A 2022 Physicians Foundation survey found many doctors feel overworked, underappreciated and unable to do their jobs to the best of their ability and establish meaningful patient rapport. More than half reported feeling burned out. But doctors also identified a range of strategies in the survey for improvement, such as removing low-value work and streamlining prior authorization.

“There are ways of staying in practice, seeing patients and living in new realities,” says Yul Ejnes, M.D., a Rhode Island-based internal medicine physician and a professor at Warren Alpert Medical School of Brown University. During the past 34 years, Ejnes has been part of small and large independent practices, the latter acquired by a health system two years ago. He urges doctors to advocate for as much control over their work lives as possible when it comes to scheduling and the size of their patient panels, as ways to combat burnout. “Doctors have to have time to get to know their patients and there is a turning point that you get to know them so well that it actually gets easier because they know you want what’s best for them,” Ejnes says.

Competition

As more people rank convenience asthe most important factor in choosing a primary care doctor, retail clinics and online health care services are growing in popularity for nonacute care, with their usage surging during the pandemic when other providers closed their doors. These care pathways are also alternatives for the 1 in 4 adults and nearly half of adults under 30 who do not have a primary care doctor, according to the Kaiser Health Tracking Poll.

Taken together, these trends are challenging the traditional model of episodic face-to-face patient care delivered by doctors and the value of care continuity. To attract and retain patients, doctors must employ up-to-date digital tools and receive support from their health systems, George says. Health care systems have done a “poor job” of communicating expectations and rationale for new pathways to care, he says. “We need to advance the patient understanding of their ‘home base’ for the care they receive.”

Re-engineering Delivery

Research has shown value-based care models enable doctors to spend more time dealing with complex cases and often yield better patient outcomes through team-based coordinated care, and at greater cost efficiencies. But health care remains stuck in the fee-for-service model, with the adoption of value-based care occurring at a snail’s pace, according to a 2022 NEJM Catalyst survey. Yet more patients are sicker today, with 6 in 10 adults having at least one chronic disease, according to federal statistics, and rates higher for the growing
older population.

Addressing social determinants of health — conditions in which people are born, grow, live, work and age — is also a growing focus in the examination room. A 2017 study published in NAM Perspectives estimates these factors are the major contributors to health care outcomes, up to 90%, compared with medical care, which is up to 20%

“My area is different; our patients are sicker, we are a poorer community, all of that matters,” says Karen L. Smith, M.D., a family medical physician who has been in solo practice in Raeford, North Carolina, for 32 years and whose patients span multiple socioeconomic, racial and geographical backgrounds. With her practice part of an accountable care organization that financially rewards for improved patient outcomes, a nine-member team backs Smith in meeting patients’ medical and nonmedical needs, including interventions around food, transportation and financial insecurities. “I know that I don’t deal with social determinants of health, like a patient telling me she’s worried about paying her mortgage and isn’t thinking about her high blood pressure, that the blood pressure problem will never get under control,” Smith says.

Patient readiness

Today, the doctor-patient relationship is guided by the principle of mutual participation. “Patients today want to be partners in care, not just recipients of care as directed,” says Randall Rutta, M.A., the CEO of the National Health Council, a nonprofit organization that focuses on 160 million people living with chronic diseases and disabilities. Although the internet and support groups are helping patients become increasingly well informed about their conditions, Rutta says, there remains wide debate around best practices for engaging them in health care decision-making processes.

For example, the shared decision-making model is being studied and implemented, although not routinely, across health care today. In this model, doctors are to actively engage patients in discussions about their treatment options and preferences, providing educational resources and tools to inform and empower them to make decisions based on their unique needs. Putting shared decision-making in practice can be challenging for doctors, due to system-imposed time constraints with patients, Rutta says — and not all patients are ready to take an active role. Older patients, for example, may simply want their doctors to take a more paternalistic approach because that is what they are used to; and health literacy and cultural and educational backgrounds have also been found to be hurdles, according to research.

Patients’ ability to manage their side of the relationship can fall short for other reasons. Surveys show many patients find it difficult to maintain behaviors like exercise and eating healthy, do not take their medications as prescribed and skip recommended preventive health services. Since the pandemic, 40% of U.S. adults say they are delaying care or going without because of costs.

Technology’s growth

Surveys show patients today expect their doctors to be up to speed when it comes to digital tools that make access more convenient. The pandemic drove adoption of telehealth, which remains a service most patients expect from their doctors; if it is not provided, they will look elsewhere. Enormous growth is also underway in the use of wireless and mobile sensing products, such as wearables, for patient monitoring, hospital at home, chronic disease management and general wellness — all tools that empower better decision-making. The emergence of artificial intelligence (AI) has been far more controversial, generating hype around eventually replacing doctors. So far, AI systems have been shown to help alleviate administrative and practice management burdens faced by doctors. They also have worked as a diagnostic support tool for diseases including some cancers, and as a risk prediction and intervention tool for patients with acute and chronic conditions to avoid hospitalizations.

Health care always has been and always will be about human-to-human relationships, trust and healing, says Steven Lin, M.D., a primary care doctor and founder of the Stanford Healthcare AI Applied Research Team. “For AI to add the most value and for patients and doctors to embrace it, it needs to support, not supplant, the doctor-patient relationship,” Lin says. “There will never be a future that I can imagine where AI takes over the role of any doctor, much less in primary care.”