I came across a really good post on The Daily Beast written by a pediatrician in New England, griping (appropriately) about parents who were unwilling to trust his judgment about vaccinating their children. The led me to ask: why have so many patients lost trust in their doctors? You might challenge the assumption that patients used to trust their doctors more, and that would be a fair question. I haven’t found any peer-reviewed studies on this, but if television is any guide to changes in culture over time, I refer you to Marcus Welby, MD vs. House. Rather benign, certainly caring and competent, thoughtful and ethical, Dr. Welby seemed to represent how most folks viewed their personal physician back in the late 60’s. Dr. House, on the other hand, came across as brusk, uncaring, addicted, untrustworthy, willing to violate his patient’s rights on a whim, a real 21st century smartass. Accept for the sake of argument that the premise of this blog is generally true. Did physicians in this country merit this transition in cultural perception from caring to untrustworthy (or at least indifferent) over 40 years, or were we the victims of cultural ambush?
You can certainly point to a lot of possible reasons why many patients no longer trust the physicians who care for them. It is certainly difficult to maintain this trust when other physicians publically recommend that people should not trust their doctor. Dr. Rost makes the argument that “most doctors are businessmen first and doctors second”, meaning that medical practice has transitioned from a profession to a crass, me-first money making operation. I personally spent a lot of time working on keeping my ER group from sinking under the weight of our mission to care for the uninsured; but I never felt that this focus on reimbursement was more important that the mission itself. Most of the docs I know care about caring, and serving the best interests of their patients; but I have to acknowledge that for more than a few docs, money matters a lot.
The most obvious things that have changed the perception of medicine over these last forty years include high profile cases of physician fraud, drug abuse, drug pushing, malfeasance, gross malpractice, even murder. What in the past was often hushed up, or discounted as highly unusual, have now become grist for the media mill. To say that physicians’ images have been tarnished by these instances would be an understatement. However, there are undercurrents that have also impacted public opinion, in a more subtle but powerful way. Physician advertising probably reinforces the view of physicians as business entrepreneurs rather than caregivers. The whole concept of capitation, not fully understood by the public but felt by patients every time their HMO provider hesitates about ordering a test or treatment and does it in a way that creates a sense of unease rather than confidence; this hits right at the heart of trust between doctor and patient. Stories about physician researchers compromising their integrity at the behest of pharmaceutical companies; advertising by trail lawyers drumming up business by pointing to horrible outcomes from what initially seemed to be great medical and surgical breakthroughs; pontification by opponents of vaccination, birth control, Obamacare, virtually anything negative having to do with physicians or healthcare: all of these reach into the fears and concerns of our patients and stoke them. We are all exposed to a lot of negative press and adverse opinions about the practice of medicine, and some, frankly, is deserved; but there is not a lot of recognition for the positives in what physicians do. Even TV shows like Mash and ER temper the good in medical practice by acknowledging, or even showcasing, the ‘human’ side to physicians and caregivers, i.e. the tragic failings of these ‘heroes of health care’. I admit that even firefighters and paramedics get similar treatment nowadays in the media, and yet they continue to retain a favorable image in the public’s eye; which raises the question: Are physicians doing something wrong here?
It is possible that we are. If physicians sell their practice and go to work for a hospital or a large corporation; whose interests are they serving, especially if the interests of the corporation and the patient aren’t aligned? Do you really need to be admitted to the hospital, or is the doctor just following the directive of the for-profit institution? Is my doctor getting ‘incentivized’ to push this drug, or that test? Are doctors spending more time doing paperwork, and less time in the exam room, because it is in the doctor’s best interests, or for the patients? Do templated EMRs accurately reflect the individual patient’s responses and exam findings, or just help the doctor ‘move the meat’. I think it is not as much that patients are having these concerns, per se; but that these kinds of activities and practice patterns have an impact on the way doctors think about themselves, and their work. Perhaps we don’t trust ourselves as much anymore.
Ok, “enough of this”, you might be saying. Didn’t a Gallup poll recently reveal that trust in doctors moved to an all-time high of 70% over the last ten years? That’s true. Perhaps all of this hand wringing I just went through is based on an incorrect assumption: we still have the trust of our patients (especially compared to the public’s trust in lawyers, stockbrokers, and members of Congress). Great. I hope this poll is accurate: but members of Congress are at the bottom of the poll at 7%, and yet they all keep getting re-elected. Perhaps those polled were thinking ‘I love MY doctor, but I’m not sure about those other guys’.
Regardless, I think it is incumbent on physicians to recognize they need to earn this trust, and not take it for granted; to watchdog their profession and those who practice it; to monitor themselves and how incentives impact their behavior and their care; to promote respect from the public and the media; and to guard against the insidious intrusion of the business of medicine on the practice of medicine. As someone who advocates actively for fair payment for physician services; I can assure you this is no easy task.