But there is nothing quite as devastating as medicine gone wrong. So somewhere along the way—maybe about the time we began doubting Congress, the president and the press—we started to look at doctors in a new and suspicious light. No one accused Marcus Welby, for example, of pandering to drug companies, of meeting patient “quotas” of some kind or of putting profits over patient care. No one ever suggested he didn’t know what he was doing or was offering the wrong treatment. No patient quit Welby for a Chinese herbalist or a chiropractor.
But certainly modern doctors deal with these issues on a pretty regular basis. “There’s a huge and growing divide between physicians and patients,” says Michael Wilkes, M.D., Ph.D., professor of medicine and vice dean of medical education at UC Davis.
We asked Wilkes—and some other locals—how we got to this point, and what can be done to improve the situation. Because unlike a tax problem or a screwed-up remodel, your very life maytion. Because unlike a tax problem or a screwed-up remodel, your very life may depend on trusting someone in a white coat.
Perfect Strangers
“If you recommend a treatment, ideally you would like the patient to follow-up,” says Louise Addison, M
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Why the lack of trust? Part of the problem, everyone agrees, is the fact that no one knows each other. This is in stark contrast, of course, to 100 years ago, when most people spent their entire lives in small towns where there was one doctor who ran a private practice out of a home office, with his wife or daughter acting as his receptionist. He delivered you, set your broken arm when you fell out of the tree and came to the house to check on your sister every day the winter she had mumps. You also ran into him uptown, went to school with his boy and knew his buggy—or Model T—by sight.
Not so now, when most of us would be hard-pressed to pick our primary care physician out of a crowd, and he might remember our appendix, but not our first child’s name. “You’re strangers walking into an office,” says Wilkes, who cites several reasons for this. “Patients change doctors a lot [now], and part of that is because insurance plans change: ‘Dr. X is not on the plan anymore, so I guess we’ll see Dr. Y.’ We’re also much more mobile as a society.” And this is true not only for patients, who live across the country from their “home town,” but also for physicians. “Ninety percent of all doctors are employees today,” says Wilkes. “And they change jobs. It also of course calls into question [for patients], ‘Who are you working for?’ Because when [small-town] physicians ran private practices, obviously they were working just for patients.”
Doctors’ motives in today’s medical system, however, aren’t always so clear. “There are many attributes to the managed care health system,” Wilkes says, “but it has raised suspicions.” Are physicians being prevented from prescribing certain drugs? Are they limited in their referrals to specialists? Is a business executive calling the shots?
Direct-to-Consumer Advertising
Another culprit muddying the waters is the relatively new practice of advertising prescription drugs straight to dumb-old-us. “It misaligns patients’ expectations,” says Wilkes, who’s done research on this issue. “First, it convinces patients there is a drug for every problem, and second, everything that is not perfectly normal is a problem. Things like baldness and toenail fungus—conditions people lived with for centuries—are now considered ‘medical diseases.’” So, Wilkes says, patients come in to the doctor’s office demanding drugs they’ve read about or seen on TV. And when the physician tells them, “Look, these treatments are very ineffective, these are silly drugs and have lots of side effects,” patients are certain the doctor is on the take somehow. “Patients decide the physician must get some ‘incentive’ or ‘just wants power over me,’” says Wilkes.
And, furthering the conspiracy theories, many managed care formularies, such as Kaiser, don’t even carry some of the most heavily advertised medicines. “I think they have a great formulary—they don’t stock this riff-raff,” says Wilkes, but we patients, with our heads clouded by marketing experts, may not see it this way.
Mr. Science
Lastly, there is clearly an issue in medicine that causes unlikely problems: science. And this is a two-parter. The first part is many medical schools, particularly in the ’70s and ’80s, put big emphasis on—and recruited—good scientists. Which, one might surmise, is reassuring: If you have a bad cancer, the leading expert in the world working on your treatment could be a relief. But surprisingly, patients are relatively unimpressed by a doctor’s scientific credentials. “There’s an old saying: People don’t care how much a doctor knows until they know how much he cares,” says John Chuck, M.D., chief of marketing, health promotion and interactive technology innovation for Kaiser Permanente. “I honestly believe the essentials for a patient-physician relationship haven’t changed in the last 100 years. And these are things like mutual respect, active listening, the sense that the doctor is in it for the long haul.”
Are all those brilliant scientists necessarily good at conveying these emotions? Not always, Wilkes says frankly: “Things have changed enormously, but there are still lots of doctors out there following a ‘disease model’—the liver in Bed 3A, the gall bladder in Bed 5—and are not patient-centered.”
By “patient-centered,” experts mean understanding both what the patient says and what is often left unspoken. “If you have a patient who comes in because they have a headache, maybe what they’re really worried about is their neighbor had an aneurysm and died,” says Chuck. “You need to get at that fear.”
This is even more critical in certain specialties, such as pediatrics, where you basically have “two patients,” according to Addison. “Even with a teenager, you know you have an anxious parent in the waiting room,” she says. “And so you need to bond with the parent, and also—at some age—the child too.”
In fact, some experts suggest Americans’ attraction to alternative medicine—and alternative health practitioners—has more to do with these issues of bonding and listening than anything resembling science. “There was an article published several years ago in the New England Journal of Medicine that compared patients with back problems,” says Wilkes. “One-third saw an orthopedic surgeon, one-third saw a family practice physician and one-third saw a chiropractor. And the chiropractor was the unequivocal leader [in patient satisfaction] because he spent the most amount of time with patients. He spent triple the time of the orthopedic surgeon, and significantly more time than the family physician. [Some of these practitioners] may be promoting silliness, but they’re giving patients something they need: attention.” Research confirms this point as well: An alternative practitioner generally spends 70 percent of an appointment listening to the patient, as opposed to the average M.D., who spends 70 percent of the time talking to the patient.
Here’s the second part of how science can rear its ugly head: Sometimes it’s wrong. Take, for example, the decades when every good physician treated ulcer patients with bland diets and orders to reduce their stress. Who knew it was really caused by a bacteria that could be treated with a single course of antibiotics? Well, unfortunately, no one. “Most doctors practice evidence-based medicine,” says Chuck. “And ‘evidence-based’ means based on the existing body of research—but future research might contradict this information.”
Remedying the Situation
Logically, of course, there’s not much to be done about many of the obstacles in the physician-patient relationship. We can’t make science be right 100 percent of the time; we can’t put doctors back in buggies, taking potatoes as payment. And whether we like it or not, managed care and direct-to-consumer advertising are probably here to stay. But there is a variable that can—and is—being manipulated by savvy medical institutions: how a doctor relates to you, when you’re the new stranger in her waiting room.
For example, many medical groups—large or small—are making sure you see “your doctor” whenever possible, and are making it easier in general to communicate with physicians. “We’re forever creating new ways to contact us,” Addison says. “You can make an appointment online or on the phone with a push of a button. You can also e-mail your doctor—patients have loved that service. Maybe it’s something simple: I have a cough and want to know what kind of medicine I can take.”
In fact, Addison theorizes the difficulty in asking basic questions is a big reason people turn to the alternative medicine aisle. “You might think, ‘I don’t feel good, but talking to my doctor is such a chore—I’ll just go to the drugstore,’” she says. “And the marketing is so fancy, you think it will solve all your problems.”
Finally, modern medical students are more apt to be role-playing with actors and actresses than bubbling test tubes in a laboratory. And places like Kaiser run every one of their 6,000 physicians through a series of classes and trainings on this very issue of “personalization of care.” “You have to be present to listen to what the patient has to say,” says Addison. “It sounds so simple, and it is so simple.”
