Communication versus Care

I am confused about the physician – patient relationship. I see doctors as diagnosticians, advisors and caregivers.  I believe patients are information sources, organizers and do the healing.  It is a team.  However, three recent events have me baffled:

First, a friend of mine went to a doctor.  She found the doctor to be intelligent, well trained, made the likely diagnosis and gave solid healing advice.  She plans never to return to him because he was rude, made poor eye contact and rushed. In other words because he did not seem to care, even while giving excellent care, she will not return for care. Then, an online study was published looking at doctor rating systems. It found patients make decisions on choosing doctors based on waiting time, office organization, visit length and social criteria. Patients do not make decisions based on the quality of medicine practiced or delivered. Finally, Theresa Brown in a New York Times Op-Ed piece noted that hospitals are routinely surveying patients and adjusting policy based on satisfaction measures, which may have little to do with the quality of care administered.

In other words, patients do not choose medical care using measures that necessarily have anything to do with achieving physical health.   Therefore, when a patient interacts with a doctor there are three possible outcomes:

1.  The physician cares and gives good care = the patient gets good care.

2.  The physician cares and gives poor care = the patient gets poor care

3.  The physician is uncaring and gives good care = the patient goes elsewhere, so the patient gets no care.

I am not certain what I should do with this information. I can to spend more time with my patients, appear to listen better, be on time and treat each patient like a relative.  However, there is no guarantee this will actually result in better individual care. Still, it is clearly part of the physician’s job to create a caring and supportive environment. The point is that not all doctors pull “caring” off and that does not necessarily make them poor doctors.  They may be incomplete, but perhaps possess great medical skill.

In our society, we put the responsibility for the physician-patient relationship on the doctor.  However, the patient is the one who suffers when the interaction deteriorates.  While it is ideal to have a doctor who can build a caring emotional environment, frequently it is more vital to have a doctor with the ability to give excellent medical care.  Therefore, sometimes, when it comes to building this relationship, I think, the burden must fall to the patient.

Probably, the first step is being aware that the simple measures by which we judge normal human contact do not always work in the physician – patient relationship. If you have a doctor who seems to have the skills and training you want, but you cannot seem to get him/her to give you the personal service you need, it may be time for you to fix that problem.

First, you will need to judge the doctor’s basic medical skill.  Where were they trained? Are they board certified in the specialty for which you need treatment? What is their reputation in the community?  When they give you a recommendation, does it jibe with other sources of information?  How do they keep current?  Do they use electronic medical records or web based professional materials?  Do pharmaceutical industry publications take up too much of their office?  Do their suggestions fit known medical standards?  Does a second opinion support their recommendations?  Can they supply you with references or quality data?  How often have they seen your kind of problem or performed the procedure in which you are interested?

In the next several years, we will see increasing true quality data. This will include infection rates, complications, survival, diagnosis volumes, procedure experience and costs.  More details beyond simple malpractice events will help patients navigate this difficult area. There will be an increasing public judgment of true medical quality.  Using this information patients will be able to choose physicians with whom they wish to build relationships.

If you believe “your” doctor has the basic medical skills you need, but does not seem to be communicating with you or giving you the service you desire, you may need to take charge.  This may entail explaining to the doctor exactly what you expect from the relationship, and setting ground rules.   If being on time is important, ask him/her how things can be scheduled to get you in quickly.  If you need more teaching time, ask how this can be arranged. If the front desk staff is disorganized regarding insurance, perhaps meeting with the office manager may help. Speak up in this critical relationship, as you would in others.

If a particular doctor’s medical skills warrant, you need to take an aggressive approach to building your relationship.  At times, the patient must build and enforce the social contract.  Your health is worth that extra effort.


  • Kathy O, semi-retired MD
    I am as confused as you are on this one. What exactly do we collectively mean by "quality" in health care? I agree that the current system of measuring "quality of care" is flawed - on the pure science/technical side (measuring only what can easily be measured and ignoring the complicated stuff) as well as on the subjective side (nice lobby, soft music, spa atmosphere... huh?). But you then seem to fall into the same trap of defining "good medical care" in terms of a dichotomy of technical stuff/expertise, and "care" ie "caring" as a separate thing. Might not true "healing" require both? If my car is broken I need it fixed by a competent car mechanic and I don't really give a hoot if he or she is an utter ass (though I might well take my business elsewhere next time). But if I'm sick and vulnerable, frightened and worried, the science AND "caring" and "healing" are all important. A large % of issues brought to the physician these days are self limited (thus, technical expertise is sort of irrelevant and caring/healing is paramount.) Of the conditions that medicine can "fix" only a very small % require only technical expertise to do so. Most are chronic conditions requiring a long term solution or palliation and hence a long term relationship--impossible to establish with an ass. You are spot on that the physician-patient relationship is a two way endeavor. However, inherent in the physician-patient relationship is a difference in power. The power resides mainly in the hands of the doctor -- information, access to medications, tests, procedures etc. To ask the patient to take on that power differential at a time of maximum vulnerability is asking quite a lot and is probably only relevant for the worried well, the person seeking routine health maintenance and the occasional extremely self-confident sick person.
    • James Salwitz, MD
      Thanks for your thoughtful comment. It is indeed a tough sell to ask patients in need to take control of this vital relationship. As a physician I do expect the doctor to be responsible. It is my thought that at critical moments a patient might exercise power in order obtain vital medical care. Hard to do, but perhaps occasionally necessary. jcs
  • I have read your article on using the word die. how often I have noticed, people will say passed. Passed what. they are even afraid to use the word. that is why people have such a fear of something that is a definite. the fact that they cannot say the word, makes it like something that is too terrible to comprehend. You said everything I have wanted to say for so long, and I thank you, amy galaudet
    • James Salwitz, MD
      Thank you very much. I suspect you are right. We can use words to avoid or to cope with the things that scare us. jcs

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