Who Will Take Care of You?
A growing gap separates doctors and patients. The new healers are now stepping in to fill the void
It is no longer a happy marriage, this relationship between doctors and patients. A bond once tight with intimacy is under incredible strain. Doctors have changed. Patients have changed. The caring is gone. Well, not gone but buried under the crush of everyday life. Buried under insurance headaches as patients now come burdened with reams of paperwork for doctors to fill out for reimbursement, paperwork that eats away at the time they might spend on other patients. So do fees, doctors say, because what insurance pays them is well below their costs. So in a vicious circle that steals more time, they have to see--and bill--a lot of patients each day and shuffle them out of the office no matter how much attention they might really need. "Family physicians are getting stressed to the max," says Mary Frank, who is president of the American Academy of Family Physicians and has a private practice in Rohnert Park, Calif., north of San Francisco.
Patients, for their part, frequently switch insurance plans to save money, but changing plans means changing care, because the new plan may not cover the old doctor. Nobody gets to know anybody anymore. "Look, docs are nice people, but they're really time pressed," says Todd Ringler, 37, a public relations executive who lives in Swampscott, Mass., outside of Boston. "I found I wasn't able to have conversations that went beyond 'Tell me where it hurts. What's the level of your pain, from 1 to 10?' If you can't go further than that, you can't develop honest communication about your health or health problems."
And going further turns out to be much more than a touchy-feely relationship issue. It is, in fact, vitally important to the patient. Research has shown that a good conversation that thoroughly explores problems and possible treatments means better health. Physician Sheldon Greenfield and social scientist Sherrie Kaplan of the University of California-Irvine and their colleagues, in an oft-cited series of studies, audiotaped doctors' discussions with a variety of patients, including people with ulcers, diabetes, high blood pressure, and HIV. Some of these patients asked more questions about their illnesses and how to manage them and participated more in developing a program of care. These patients and their physicians said they had the best communication. And after they completed these visits, these patients also had the best control over their blood sugar and blood pressure levels, reported fewer limitations on their lives, and took their HIV medications on schedule. It's not really surprising that they did better with their treatments. After all, they had an active role in devising them, a role allowed by these detailed conversations with their physicians. The doctor-patient relationship, the researchers concluded, "must be taken into account."
"This relationship has clearly been shown to affect diagnostic accuracy, adherence to treatment plans, and patient satisfaction," says internist Wendy Levinson, chair of medicine at the University of Toronto. "And the most important part of patient satisfaction is communication with the doctor. Repeatedly, we've found that people will put up with hassles like longer waiting times if they have this good relationship."
So where did the time to build that relationship go? The average physician visit hasn't shrunk; from the late 1980s through the end of the 1990s, it has hovered between 16 and 22 minutes, depending on which survey you look at. But what's happening is that both doctors and patients are walking into that visit with new, expanded agendas, says Dana Safran, director of the Health Institute at Tufts-New England Medical Center and another researcher who monitors the doctor-patient pas de deux. "Patients have taken to heart the message to be informed and smart, and they are coming in with a lot more questions and a lot more of their own info that they've taken off the Internet and from other places," she says. "Doctors, for their part, have their own concerns." If they don't ask a lot of straight biomedical questions, insurance companies and healthcare oversight agencies will penalize them, making it harder to get paid. So while the office visit didn't get shorter, docs and patients need to say more than ever in that same tiny time frame.
Psychosocial ties. So something gets cut out. And what docs cut, says Levinson, are the psychosocial aspects of the visit. "They're not asking about patients' lives, about their communities, about anything that leads to continuity of care," Levinson says. "And these are exactly the questions that patients want to be asked and need to be asked. The biomedical and the psychosocial are so intertwined in primary care."
And that's why Todd Ringler sees Anne Krekis, his nurse practitioner. "I've been seeing her since 1992," he says. "She really knows me, and I have complete confidence in her and her clinical ability. For instance, I used to be a social smoker, you know, out in a bar. Anne and I had a discussion about it, about the risks to my health and to my family--I have kids--and I never had that kind of talk with a doctor. I've had to switch health plans, or switch care centers in the same plan, and they tell me to get a new primary physician. And I say, 'Fine. Give me anyone. As long as they work with Anne.' She does my annual physical. She's who I call when I get sick. She really is my doctor."
This story appears in the January 31, 2005 print edition of U.S. News & World Report.