How doctors and patients communicate — and what it means for careYou find yourself in an alien place — a matte-finish office both clinically anonymous and drearily familiar. You wait. A stranger weighs you. Your blood pressure is taken. You take off your clothes. Your blood pressure is taken. You wait.
This is how you will meet your doctor. That this person belongs to one of the most culturally weighted of professions — that they are long and expensively educated, well-paid, and well-respected members of the community before their name is even uttered — is the longer subtext to the fact that you are sick and need their help.
Doctors are, of course, aware of this. A new body of research suggests that the power imbalance is actually so deeply ingrained in the medical profession that doctors instinctively adapt to manage it. In this view, it’s part of the “hidden curriculum” of a medical education, learned through socialization and practice — something like the way high schoolers learn to drink or date.
Changing the Balance
That this method is plainly imperfect is obvious to patients (and high schoolers) everywhere. “Health care consumers are truly the Rodney Dangerfields of medicine: ‘I don’t get no respect,’” says Dr. Eric Topol, an advocate of transformative change in the delivery of care. In fact, in his view, the patient’s sense of powerlessness may lead to fundamental challenges of old orthodoxies regarding how care relationships are supposed to unfold.
“Increasing frustration and vexing aspects of health care today may influence a bottoms up movement, propelled by smartphones and social networks for improving the future of medicine,” he suggests.
In his book on the possibilities of the new digital landscape — fittingly titled ‘The Patient Will See You Now,’ Dr. Topol relates the story of having a patient message him a real-time ECG showing a cardiac event in progress and asking what to do. At that moment, he recalled thinking, “I knew the world had changed.”
By and large, patients are enthusiastic about that change; the same is not always true of providers. Dr. Topol notes that two out of three doctors won’t email their patients, even though it’s a proven method of ameliorating care. Likewise, with liability a constant concern, providers often prefer to invite patients to medical facilities rather than prioritize home care. This is sharply at odds with the patient preference, which is usually to guide their own care and avoid admittances if possible.
According to reformers, the patient’s reticence is well justified. A sixth of all deaths in the US each year occur at hospitals from preventable, care-related events. And even for routine health practices, empowered self-monitoring has the significant advantage over the usual doctor’s office model; in the case of blood pressure management, dozens of studies have confirmed it.
The case for change is a powerful one, but the fact of it has been difficult to negotiate. When it comes to our bodies, we are of course risk-averse, and entrenched methods can take a long time to cede ground to new technologies. Techno-optimists were spectacularly wrong about medical startup Theranos’ supposedly revolutionary blood draw techniques, and no doubt other posited technologies will fail to take hold in the complex landscape of healthcare. Even if change seems inevitable, doctors — and all others entrenched in the old guard — have reason to be cautious.
Time will continue to tell, though. Trisha Torrey, a patient advocate, sees the trend moving along generational lines — which implies that the changes are likely to continue along the trajectory towards more empowered patients. Seniors are “still very much about the doctor is God,” she says. “But Baby Boomers and younger — not so much.”
This points to a fundamental insight: that the most dramatic change taking root in the patient-provider relationship is perhaps a psychological one. If new technologies are, slowly but surely, concretely altering treatment practices, the proliferation of knowledge has radically transformed the patient’s perspective on their own care — effectively demystifying a process that was once the sole purview of medical professionals. When patients can take their own real-time ECG and note irregularities, the opaque aura of expertise that doctors once projected becomes more translucent.
Too Much Information?
This kind of empowerment, however, is a double-edged sword — and for doctors, its own source of frustration. To them, it’s often illusory; an idea more than a fact. “I think you’re seeing that patients probably think they have more power. I think because there’s more consumerism within medicine people have a U.S.-style consumerist (approach) where ‘I have all the information, you should do this treatment because I think this is what I need,’” said one study participant, an internist. Although doctors strive not to talk down to their patients, this anonymous quote hints at the broadly felt exasperation in the medical community at the tenor of consultation in the age of WebMD. Ironically, people may come to feel overconfident about their own expertise rather than inadequate, which can affect the balance of power in a negative way — ultimately reducing the quality of care.
The equation is not so simple as making X equal to Y; patients cannot be the equals of doctors in their knowledge and training, and the power imbalance must necessarily persist. Even in this, though, nuances exist that traditional medicine does not sufficiently address. Newly invigorated holistic philosophies are gaining traction even in academic circles, with the understanding that patients possess important information that doctors do not: intimate knowledge of their own bodies — and their needs as human beings.
In this context, the new technologies that patients are so eager to embrace may best be understood as an expression of the desire to communicate that wisdom. Patients are trying to translate what they have to say into a foreign language — the better to reach out to the native speakers. It’s an effort that both sides of the waiting room would do well to appreciate.