In the evaluation of the complaints that Luigi Mangione and his advocates have leveled against the insurance industry, we must home in on the underlying relationship that forms the core of medical care — the relationship between the patient and the physician. The actions of the insurance company are simply efforts to modify or enhance the primary patient-physician relationship.
A recent article in the Wall Street Journal focused on one major element of this topic — the loss of trust that patients have recently had with the healthcare system, including their physicians. I will give some of my thoughts on the interaction with physicians and what seem to me to be misperceptions. The article in the WSJ mostly recounted complaints about misdemeanors that, to me, reflected perfectly reasonable behavior on the physician’s part and showed a misconception with how medicine has evolved since the days of Marcus Welby and Dr. Kildare (or Dr. House and Dr. Robby for the younger generation).
For example, one interviewee in the WSJ article was irate because he and his spouse see multiple doctors, and “Every time they see a new doctor, they have to retell their story which erodes trust because they don’t feel listened to or known.” Reading this, I thought that many patients now are more elderly than in the past and so have multiple chronic conditions, necessitating multiple doctors (the average older patient takes four medications chronically — many take up to 15). I am a TV addict and on “Law & Order,” when Detective Lennie Briscoe and his partner go to see a victim or a witness for an interview, the victim always says, “I just gave all this information to the other detective — do I have to do it again?” Briscoe just rolls his eyes. But yes, in like fashion, every doctor likes to, and should, gather his/her own info in his/her own way. The patient should be grateful that the physician is careful enough to do that and is not just copying over a note from someone else.
When I did my residency, I was on call every third night and only occasionally managed to get some sleep now and then. My attendings bragged that in their time they were on call every other night. How did they manage to do that? The answer is that they slept much of the night. That far back, we did not have all the fancy and sophisticated diagnostic, radiographic and other equipment we have now, nor the interventions we have now. There were no ICUs nor CCUs. So when you admitted a patient to the hospital, you did a few simple blood tests, a chest X-ray, hooked the patient up to an IV, gave them a pain or a sleep medication, went to sleep, and waited for morning.
The advances in medicine in recent years are overwhelming. They are an incredible blessing in extending and improving the quality of our lives. But their sophistication exceeds the ability of the old-time general practitioner to master them. Thus, we are in a medical environment that demands multidisciplinary care for most people at some point. And because, as I said before, those of middle or older ages develop multiple medical illnesses, they almost inevitably require more tests and more physicians for proper care.
The other “problem” to which the WSJ article alluded was the increased reliance by people on other sources of information. Way back when, it was not easy for me to get information — I had to lug around medical textbooks or similar old-fashioned sources. The internet has made my life easier as well as that of patients and their families. Am I disturbed if a patient comes in and his son asks me about a treatment he read about on Google? Why should I be? Should he be disturbed if I am not prescribing some treatment that was recommended in a chat room but never validated in a study? Well, that is his problem.
Another problem with trust is real and that arises from unrealistic expectations. A patient walks into a primary care physician’s office with back pain or abdominal pain which are omnipresent common symptoms. While it is true that somewhere on the list of possible causes for these symptoms is cancer, it is a low probability problem, unless other symptoms or signs exist, and therefore it is perfectly fair to treat the pain symptomatically and conservatively and see what happens rather than immediately doing a mega workup. Cancer does not usually move that fast and therefore one can take it slowly and see what happens. Most pain will resolve or prove to be other things, and if it proves to be cancer six or seven weeks later, or even longer, it cannot be argued that significant harm was done to the patient.
Similarly, even now, many cancers are difficult to treat or fatal from the get-go. A reasonable effort to prolong life and to improve quality of life is often what one can reasonably expect. Does it erode trust if cure is not achieved or is not on the drawing board for a patient?
Trust is also nullified by a lack of faith in the quality, competence or ability of the physician. This stems from a variety of etiologies — we shall address this in next week’s article.
Alfred I. Neugut, MD, Ph.D., is a medical oncologist and cancer epidemiologist at Columbia University Irving Medical Center/New York Presbyterian and Mailman School of Public Health in New York. Email: ain1@columbia.edu.
This article is for educational purposes only and is not intended to be a substitute for professional medical advice, diagnosis or treatment, and does not constitute medical or other professional advice. Always seek the advice of your qualified health provider with any questions you may have regarding a medical condition or treatment.
