Relationship vs. Stewardship – Patients vs. System

screen-shot-2016-10-01-at-8-25-09-amFriends can speak without using words. Marketers used people sharing private looks to create a brilliant ad for Lexus. It sells cars using relationship.

Medicine starts and ends with the doctor-patient relationship.

Patients want their doctors to care most about them, not about society, or the greater good. Patients want to feel they have an exclusive relationship with their doctor; one that sees them as a unique and important.

This creates a problem:

How can doctors have exclusive, therapeutic relationships with patients and, at the same time, be stewards for the greater good?

With unlimited money, doctors can pretend to put their patient’s interests first and try to please society at the same time.

But at some point, doctors must choose: Do they do what’s best for the patient in front of them, or do they do what’s best for the community as a whole?

Medicine became loved and respected for choosing individuals. Medicine works on relationships, exclusivity and individuality.

Relationship: An Offensive Idea?

At minimum, relationships are:

Exclusive

They rest on mutual sacrifice, commitment and a level of devotion not shared with those outside of the relationship.

Organic

No matter how hard parents try to keep teenagers apart, relationships happen. Time, shared circumstance and adversity build deep connections.

Privileged

People expect help from friends and family in a way they could never expect from a stranger. Relationships build on immaterial privilege; financial gain follows, if opportunity allows.

Serve people, not ends

People benefit from relationships. Only sociopaths consider how a relationship functions for the greater good. No one stays in a relationship to serve the greater good. Healthy relationships are not strictly utilitarian.

Restrictive

Relationships place expectations on us. We cannot do or say whatever we want without risking the health of our relationships.

At minimum, relationships are exclusive, privileged, restrictive, organic and anti-utilitarian.

Relationships seem to offend most progressive social virtues.

Take equality: Social activists appeal to equality to justify everything from Occupy Wall Street to outlawing private medical insurance in Canada.

Equality has intrinsic ‘truthiness’. We equate equality with democracy. Everyone gets an equal voice. One person, one vote. We are all equal in the eyes of God.

But if we use death toll as a measure, social experiments of forced equality have created the greatest amount of human suffering in the history of the world.

Relationship vs. Stewardship

The doctor-patient relationship is the starting point for doctors to decrease suffering. It is the sine qua non of medicine.

All things being equal, doctors welcome stewardship and the chance to avoid waste, to work for the greater good of society.

But when a doctor sits with her patient, she must not think of the greater good, before the good of the patient in front of her. If she does, she stops being a doctor. She becomes a bureaucrat. We need bureaucrats, who work for the greater good, just not in the doctor’s office.

If doctors became utilitarians, it would take a generation to recover patients’ lost faith in the medical profession.

Utilitarian doctors supported involuntary sterilization in Canada until the early 1970s. European utilitarians saw the benefit of caring for ‘productive’ members of society, before those who would never leave a hospital bed.

The cold logic of utilitarianism must always clash with the doctor-patient relationship, at some point.

What does this mean for healthcare?

We describe what is, not what should be. Description imposes limits, not by fiat, but by nature: Square pegs do not fit into round holes, without changing the nature of either one, or both.

Well-intentioned calls for stewardship must face the nature of medicine.

Medicine is based on exclusive relationships. The doctor-patient relationship, by definition, excludes other people.

Medicine is, at its core, non-utilitarian. It is individualistic.

Grand ideas to fix healthcare must start with basic facts about medicine, if we hope to make things better, not worse.

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11 Replies to “Relationship vs. Stewardship – Patients vs. System”

  1. Relationships are important in medicine, so it is interesting that “new way” has patients trying to make relationships with teams rather than their doctor. This actually breeds contempt on the part of patients and a fundamental disconnect for the doctor. I see other doctor’s patients as a consultant in addition to my family practice and I often have patients call my office directly for some of the more unusual services I provide. Those with referrals have their consultation covered by OHIP and their PEM doctor shouldn’t be negated because I have a focussed practice designation. Those without have to pay for one if the service is not insured. My staff tell people they need a referral from their doctor to get the consult visit paid for by OHIP esp if it is an insured service and to avoid penalizing their doctor. Increasingly what we get is a referral from a walk-in clinic rather than the family doctor because the pt whose doctor is in a FHO or FHT is too inaccessible to get a referral. When I tell them that their doctor may be penalized for them seeing me (I can’t bill a consult which should stop the negation) most of them say that s/he is getting paid no matter if they see them so they don’t care. Some relationship eh? No mutual respect being created at all. The doctor-patient relationship is being undermined and squashed by these depersonalized enrollment models where the doctor is just another cog in the machine.

    1. Very interesting point, Ernest. You give a great example of how the structure of the system directly impacts and changes the nature of the doctor-patient relationship. We could say that the system changes the nature of medicine, since the doc-patient relationship is the core of medicine. System planners adjust the ontology of medicine, and we let it happen.

      I struggle with whether we might need something other than a union-equivalent to vouch for doctors/medicine. It looks like we take whatever we can get and give away the most important parts because governments refuse to pay us for protecting the heart and soul of medicine.

      Thanks so much for sharing this! Great example.

      Cheers

      Shawn

    2. I dare say, Ernest, that sometimes, doctors are inaccessible but, other times, patients simply can’t be bothered. For example, as a patient, I could theoretically put forth the effort to make an available 2pm appointment with my primary care physician, but why not just toss a dart and go to the closest walk-in whenever the heck I want?

      The system creates a situation where doctors are punished for things entirely out of their control.

      1. Great comment, Mathew!

        Sorry it took so long for me to get to it. You raise a very important point. We need to design the system around patient needs and preference, and stop castigating them for doing what’s in their best interests. At the same time, we cannot punish doctors when patients behave in ways that do not benefit the system at large.

        Thanks for taking time to share!

        Cheers

        Shawn

  2. Sometimes I think it’s almost instinctual, reaching out to a physician or to a nurse for help, comfort, reassurance.
    I’m in Venice, Italy right now and have just been summoned to a shop: “Is there a doctor anywhere?”

    A man has just had a seizure and is post ictal. His shocked wife is in tears and terrified. He does not have a seizure disorder. So what can I do with 2 and 1/2 decades of emergency experience behind me?
    Ensure the ambulance has been summoned. Check he is breathing and in recovery position. Check his pulse. Ask questions. Past history? Meds? Allergies?

    The ambulance is coming. I suggest I can leave. “Please don’t leave” the anxious wife implores. So even though I feel I can do nothing, just my presence is a comfort to this woman.

    1. Wow. Alicia, what a powerful story. What an opportunity to make us all proud!

      Doctors serve patients, even when we cannot ‘do’ anything. People outside medicine will never feel your story. They will hear it but not understand what it means. We need to figure out how to tell stories like you just did. Maybe some people will understand.

      Thanks for writing!

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