Despite all the attention paid to patient satisfaction, empowerment, and doctor/patient communication in the last number of years, true collaboration between physicians and those in their care is rare. The ideal of “shared decision making” is broadly embraced but equal partnerships are difficult to find.
When this phenomenon is studied there is a often a divide between how MDs think they are doing and patient perceptions. Doctors “believe” that they are open and sensitive listeners but patients “feel” otherwise. Intent and perception are disconnected. According to Dr. Dominick Frosch, a researcher at the Palo Alto Medicine Foundation Research Institute, many physicians believe they’re already engaged in shared decision making. So why don’t patients perceive it?
The easy answer is that neither doctors nor patients have truly abandoned the “physician as authority” paradigm despite several decades of encouraging patients to take more control of their health care. Another possibility that patients feel vulnerable to retaliation if they challenge their doctors advice.
Dr Prosch and others believe however that there may be something more structural in our health care system that prevents progress in this area. Perhaps the single largest factor is time. Partnerships, understanding, and trust take time and most physicians just don’t have it. Patients understand perfectly well that they will only have minutes with their doctors and are very reluctant to get into broader, time consuming discussion that it takes to collaborate.
Diagnosis are often inexact and treatment options can be varied and discussion over what would be most effective and comfortable for patients requires time. Instead, significant health care decisions are often made in fifteen minutes. Patients often find it easier to just accept the MD’s opinion and direction without consideration of their own understanding and experience of their bodies.
Another structural impediment to partnership is the physical and bureaucratic infrastructure with which we deliver health care. Visiting ones doctor entails passage through multiple gateways: phone appointment waits, empty encounters with desk staff, forms to complete that you’ve completed many times before, a nurse who repeats questions from the form you just filled out, and then another wait. By the time the doctor arrives one already feels like a supplicant.
The doctor’s office and its protocols also set up an unbalanced relationship. The doctor may be standing up and your are seated. The doctor has access to the computer and/or your medical records and you do not. You are required to undress and she is not.
The doctor is in a familiar workplace and you are in a place you only visit infrequently.
To even begin to address some of these structural impediments to doctor/patient partnerships would take a radical rethink of how we deliver health care. If you will notice however, none of these infrastructure and bureaucratic barriers are controlled by the physician himself. They are either deeply imbedded into our cultural norms or else they are enforced by larger, overarching institutions such as hospitals, HMOs, insurance companies, and sometimes governmental regulations.
Physicians, just like us, are “little people” in this system. We may or may not give them power in the treatment room but outside of it they are just as powerless to make change as we are. Perhaps the first partnership in which doctors and patients join equally is one that begins to challenge our health system infrastructure so that we can work and be treated in a humane environment.
