All great stories include magic. Characters dance around rules or constructs that define their world.
For example:
Guess my name and you may keep your child.
Find love before the last pedal falls or remain a Beast forever.
Never say the name of he-who-must-not-be-named, or Death Eaters will find us.
Magic applies to non-fiction, too. We buy books about real, faulty people who win despite their flaws.
We want stories about people struggling and limited in the same way that gravity limits us. Limits and faults make real life and fairy tales come alive. Gravity is magic by another name; no one knows what it is.
Doctor Patient Magic
Medicine has its own magic, the doctor patient relationship, that defines and controls medicine every bit as much as gravity rules us. Special cases, like indoor skydiving, artificially eliminate gravity, but they prove the rule.
The doctor patient relationship rules medicine no matter how much team care we adopt.
Teams add value. And physician extenders allow docs to see more patients. But if we seek to undermine the doctor patient relationship with teams and extenders, we undermine medicine.
Patients suffer when we ignore doctor patient magic. This is the only reason to care about magic at all.
After 3000 years, surely medicine has tried every possible combination of team care, delegated acts and self-care. But patients still want to know, and be seen by, their own doctor.
If the doctor patient relationship is the rule-which-must-not-be-broken, then we should be vigilant and exercised by anyone who fumbles the rule.
For example,
If government offers a bonus for doctors to provide less care, doctors must vote No.
If government cuts fees so much that the only way to earn a living is by cutting time with patients, doctors must resist, even if they get called greedy for doing so.
If doctors can delegate all direct medical care for some patients to other providers, doctors should resist, no matter how much money government offers for such delegation.
Many doctors get paid the same whether they make patients wait 1 hour or 10. Doctors should fight to change this.
Some hospitals pressure surgeons to manipulate wait lists for better data. Surgeons should fight for patients, not data sets.
Some hospital radiologists have to choose between capital equipment purchases and limiting the number of tests they offer patients. They should fight for tests, not budgets.
Why?
Each of these issues breaks the rule of medicine. They ruin the magic.
Soon after introducing a third party payer, the payer becomes manager. He who pays gets to order the wine. Both doctors and patients have less choice about the menu. This is a certainty, not a possibility. And only eternal vigilance can prevent a shrunken menu.
Call it magic or a rule. You can even call it a fault. No matter what you call it, the doctor patient relationship places an arbitrary cage around what we can tolerate in healthcare.
It is the rule-that-must-not-be-broken, or patients suffer.
Post Script
We’ve discussed this before: here, here and here. But why raise it again?
I believe that we must challenge accepted thinking before offering solutions. We need to debate the thinking behind solutions before we debate specific solutions themselves. Otherwise we are just negotiating terms to an already assumed agreement.
I want to write a book about the core ideas that people don’t debate. The first idea is relationships. I want to know what you think.
Do relationships form the core of medicine?
If so, do they put any limits on medicine or are they just a quaint bit of history?
Are relationships the place to start, or do you see some other idea as more important?
We’ll tackle other ideas over the next few weeks. Please share your advice in the comments below.
Thank you!
The team-based primary care model known as Nuka developed by the South Central Foundation (SCF) in Alaska acknowledges the “magic” of patient relationship with family physicians while optimally engaging the skills of very diverse teams. In US primary care models, Physicains Assistants (PAs) play a more significant role than in Canada. Each SCF team is anchored by a family doc or PA but rostered pateints are encouraged to seek care directly from any member of the team with an assurance that their FP/PA always stays informed about their care and will step into the care process when the skills of a FP/PA clearly needed. When I visited SCF and spoke with pateints and FPs, both expressed strong support for this care model. Indeed SCF uses the term “customer-owner” in place of pateint because the native Alaskans relying on SCF for care actually get to design their primary care system based upon their values and preferences.
Thank you, Dennis.
I agree. As I said in the article, “Teams add value. And physician extenders allow doctors to see more patients.” I love team care! My only point is that we must watch that our passion for teams does not undermine the doctor patient relationship.
Thanks again for taking time to read and share a comment!
Cheers
Shawn
Thanks Shawn for this post. It resonates very deeply with me. It helps to have someone articulate it clearly and remind me of the many ways I can keep the relationship at the core and not allow compromise.
Thank you for taking the time to share this, Brenda! There are bigger issues at issue that just a bit of irritation over Bills 41 & 87…
“We need to debate the thinking behind solutions before we debate specific solutions themselves. Otherwise we are just negotiating terms to an already assumed agreement.”
Well said, Shawn. This is a variation of ideology’s predetermining the conclusion and then looking for reasons to reinforce that predetermined conclusion.
Thanks for sharing this, Gerry!
Too often people look for evidence to support predetermined conclusions as you say. This kind of evidence and ‘research’ fills many policy journals. Anyone who dares to ask a question that undermines the ruling paradigm gets ostracized and overlooked for promotion.
We need brave people who will speak up and challenge the ruling paradigm.
Thanks for taking time to share a comment!
Talk soon,
Shawn
That jumped out at me too, Shawn.
If you’ll think about it, that’s how all brilliant, righteous lawyers (and judges) work. They look [backwards] at past case history and examine them with a fine tooth comb, before bringing a case.
You’re correct. We should do the same in healthcare…and, it could well apply in most situations in life. Very wise!
This is my first read of yours. I’ll be coming back for sure.
Thank you Shawn!
Hey Rann,
Thanks so much for reading and taking time to share a comment! I really appreciate it.
Looking back seems to boring and almost anti-innovation. But how is ‘looking back’ any different from using the best available evidence to guide present decisions?
Thanks again!
Talk soon,
Shawn
I truly believe that relationships are the core message in everyone’s life. I believe that at some point in our lives, sometimes at the end of it, most individuals come to the realization that the most important thing is the relationships we have fostered. The quality of the joy in our lives is measurement of the quality of our relationships.
In the helping professions, especially the field of medicine, the most important aspect in terms of healing comes with the level of trust established between the patient and the doctor. Without trust the physician can’t even begin to help the patient in the best way possible. It’s only through trust that a patient will unveil truths and important information that may be critical to see the whole picture or puzzle. Without trust a patient will not admit to not taking a medication in fear of being judged. A patient will forge their diabetic log or BP measurements etc. Without trust a patient won’t open up to an internal emotional pain that they’ve hidden from the world and maybe even from themselves.
Doctors are inherently given trust as part of the social contract embedded through history. It is only through fostering and learning how to nurture that trust will the patient share more. Trust is the foundation of making a great doctor patient relationship and is the foundation of creating greater wellness and healing in all respects. It’s been proven that the quality of the doctor patient relationship will determine the efficiency in the way a patient heals and recovers.
Their are different levels of “functioning” in health care…we can be a technician, a diagnostician, or a healer. As a physician true healing looks at the emotional, spiritual and physical aspects of an individual. We as physicians understand the physical aspects extremely well through the scientific method but we can get lost when we ignore the magical aspects of fostering proper relationships in a clinical setting.
I believe one reason people are attracted to alternative practitioners is because they focus on nurturing the relationship with individuals. As physicians we need to be reminded of the creating great relationships with patient as that shows true leadership in an environment that is being muddled with too much medical information.
Moving forward, medical leadership requires becoming better at nurturing relationships as well as not losing established systems we have built through our past medical leaders. I whole heartedly agree with you that the magic exists in fostering the magic in the doctor-patient relationship. That makes your article truly magical and something I can really relate to at many levels personally.
Well said, Lalit!
I especially like this part: “…different levels of “functioning” in health care…we can be a technician, a diagnostician, or a healer. As a physician true healing looks at the emotional, spiritual and physical aspects …”
We often talk of the art of medicine as though it were a bit of sugar to help make the medicine go down. It’s as though medicine would be fine without the fluffy stuff we have to add, just to be nice. This thinking is not only wrong, I think it harms patients. Art is the means by which we record and communicate human experience. It’s impossible to say what it felt like to experience even something as basic as swallowing by using only scientific language.
Thanks so much for taking time to read and share a comment!
Talk soon,
Shawn