It is truly a relationship like none other. One person enters into this partnership freely and bares their personal history and “dirty laundry” to the other, hoping for and anticipating sage advice and perhaps a remedy. The other enters wielding the perceived batons of knowledge and power, listening to the tale of the other, processing the information in a sympathetic manner, forming a plan, and offering a reasonable resolution. Somewhere throughout all of this is an exchange of information, knowledge, and money. There is a mutual understanding of respect, honesty, privacy, and confidentiality inherent in this relationship. This is the ideal tale of the patient and the doctor.
Or so we like to think. The doctor-patient relationship is one that has stood the test of time relatively well. It certainly has lasted longer than Kim Kardashian’s marriage. In some respects, it is the ultimate relationship between two human beings. For the patient, a chance to seek advice or a cure for the illness that ails in an environment free of judgment. For the doctor, a chance to practice his/her skill, to comfort the sick, and to alleviate suffering. All of this in a place where both patients and doctors are supposed to – rather expected – to be honest, forthcoming, and truthful.
For years however, physicians have been taught to question and critique our patient’s responses. A question asked does not always elicit an honest answer. Over time, medical education has taught students and doctors alike to begin with broad, open-ended questions – allow the patient to tell their story without interrupting – and then slowly move into pointed and more directed questioning. Obtaining a patient’s history became more detective than doctor. This view isn’t entirely cynical; patients are often unable to recall every detail – information that can be vital to physicians but may seem relatively minor to patients. Patients may be so overwhelmed by their illness that they cannot remember everything… and who can blame them? Those with complicated medical histories are unlikely to remember who removed their tonsils some 40 years ago or all 25 of their daily medications. Patients are often anxious and more often embarrassed – it can be extremely difficult to reveal the intimate details of one’s private life to someone who increasingly may be a complete stranger.
So doctors learn to question. The old social history question “do you drink alcohol?” turns into “how much alcohol do you drink in a week?”; “do you smoke?” has become “how much tobacco do you use in a day?”. At the heart of our questions is truthfully a fact-finding mission; but there is a degree of skepticism that often assume varying amounts of omission and dishonesty, whether intentional or not.
Several recent articles, however, should give patients reason to pause and question as well.
A survey of 1,900 physicians performed by researchers at the Massachusetts General Hospital and published in Health Affairs reported that nearly 20% of respondents did not report mistakes to patients, close to 40% did not report ties to pharmaceutical companies when prescribing medications, and almost 45% reported painting a better prognostic picture than reality to their patients. The study authors also pointed out that these results may be lower than the reality, as physicians may have responded to the survey questions according to their perception of the professional standard rather than their actual practice. The results of the survey suggest that perhaps both sides of the doctor-patient equation are less than forthcoming with the truth, the whole truth, and nothing but the truth.
And as Dr Pauline Chen points out in her article in the New York Times, even when physicians may be telling the truth, the information coming out of their mouth may be less important than the words their body language is saying. Patient’s perceptions of how we speak may be far more important that what we actually say. Communication is incredibly important, regardless of how honest it is, and can often be overshadowed by the delivery. Chen’s article is even more astounding given the emphasis in medical education on communication skills. Countless hours of curricula are spent teaching medical students not just the information necessary to become a doctor, but equally important how to act like one and how to convey that information in a way that is palatable to patients. Students are placed in a variety of settings throughout the four years in medical school to test, alter, and hone these communication skills through video tapes, standardized patients, oral exams, and patient feedback.
I’ve often told medical students that learning how to be a doctor was reserved for intern year; learning how to act like a physician is a skill that should be acquired in medical school. Part of this “act” includes learning what to say and how to say it. But as last week’s articles point out, what are we really saying?
Physicians often justify their lack of honesty in many ways; the most popular reasons include lacking sufficient time, patient’s inadequate knowledge, or the belief that the information would be harmful to patients. These reasons not only carry the sting of paternalism but are, quite frankly, insulting to patients. The physician who chooses dishonesty over careful explanation is clearly shirking his/her duty to the patient. The physician who bends the truth because he/she believes the patient lacks the appropriate knowledge to fully understand has clearly not done a sufficient job in explanation. The physician who assumes that an honest assessment of prognosis would be detrimental to a patient’s emotional well-being has clearly neglected to ask that patient when would be appropriate to broach the subject. Likewise, our honesty has left them uninformed, not fully aware of the possibilities and probabilities they so desperately need to know to make truly informed decisions about their care. Furthermore, these assumptions, reasons, and accusations are no longer acceptable, particularly since patients are increasingly knowledgeable and self-advocating, and unfortunately increasingly skeptical of and disappointed in the medical community. This week’s articles, unfortunately, only add fuel to the fire of suspicion in their minds.
Ultimately, our responsibility as physicians is to treat our patients both equitably and honestly. We are the ones charged with the duty to alleviate pain and suffering, to enhance well-being, and to promote health by working with our patients. For the sake of our patients, we owe them a doctor-patient relationship that is rooted in trust. Because if we ultimately fail to step up to the plate in a relationship predicated on honesty and trust, can either party ever truly believe?
Original Health Affairs article abstract (referenced in the Boston Globe article; contact me if you would like to read the full journal article and I’ll try to get you access)