Abstract
Keywords: Patient-physician relationship, collaborative care, physician-patient partnerships, evidence-based medicine.
Citation: Elias P. Relationships will never be obsolete in medicine. J Participat Med. 2013 Feb 8; 5:e6.
Published: February 8, 2013.
Competing Interests: The author has declared that no competing interests exist.
I have always believed that the relationship between the patient and their clinician is a vital part of care. In fact, the central role of relationships with patients is a huge part of what originally drew me to medicine and then led me to select primary care as my career. I still believe that successful and rewarding collaboration with my patients depends to a large degree on the quality of our relationships. But I wonder if I have misunderstood what is going on.
It began a little over a year ago with a conversation in an airport. My wife and I were flying to Seattle to meet our newly born grandson in Port Angeles, Washington. After some idle speculation about the personalities and private lives of the cabin and flight crews, we agreed that we really didn’t care AT ALL whether the pilot was conservative or liberal, nice to his family, a good conversationalist, or even a decent human being. All that mattered to us was his competence and skill: would he deliver us safely to Seattle? During the flight, as I chewed on that idea, it dawned on me that I had heard many patients say they didn’t mind that the consultant or surgeon to whom I had sent them was an arrogant or rude jerk, as long as he did a good job (taking out the tumor, putting in the total knee, injecting the nerve, managing the seizure medications, etc). In fact, I occasionally apologize in advance for the personality of a consultant with the rationalization that “he is really superb at what he does.”
It has occurred to me that, perhaps, the importance of a relationship and the need for connection (on both sides) is not because it is necessary to make the product work, but because the product is unreliable?
The more I think about it, the clearer it becomes. I don’t need a relationship with my airline pilot or with the air traffic controller who hold my life in their hands when I fly. Or with the contractor I hire to roof my house, or fix the foundation of my barn. Or with the on-line systems for banking and making travel arrangements. I engage in these activities happily and with trust because I know the product is reliable and good. In short, I don’t have to trust the intermediary because I trust the product.
Medical care is different. It still bears the burden of centuries as more religion than product. While every year brings progress towards a reliably effective and scientifically driven product, both patients and clinicians are still operating in a universe where diagnosis, treatment and outcomes are uncertain more often than certain. We cope by replacing the uncertainties of the medical process with the dependability of a relationship between the clinician and patient. Our faith that the clinician will give his/her best effort is a stand-in for assurance of the dependability of a good outcome.
When (or if) medicine, the biological applied sciences, and artificial intelligence reach the point where diagnosis and treatment are as accurate, effective, and reliable as online banking or air travel, we may well find that stories of deep and trusting relationships with flawed and error-prone clinicians are a subject of humor and relegated to history books. Future generations may laugh at our reverence for a collaborative relationship with a skilled and empathic clinician, even as we laugh at the faith primitive societies placed in their shamans to predict and influence the weather, crops and their fortunes in battle.
Fortunately (or unfortunately), this is a reality I am certain I will never face. We are still immeasurably far from a future where data driven algorithms and personalized genomic computer-delivered medicine actually works. The hard part, of course, is not our ability to understand the pathology, but to understand the patient! Despite its impressive start, evidence-based medicine, with all its algorithms and best practices, is nowhere near rendering the partnership between the patient and a caring clinician obsolete. For many years to come, I (and at least several generations of clinicians to follow) will be called on to forge and maintain collaborative relationships with patients as the vehicle that supports and delivers care, and makes us feel good about the process.
A fantastic future of purely scientific medicine that always works may eventually come to pass. And it may be a good thing in its time. But, for now, we should use the science we have as best we can, without pretending it is more than a primitive set of tools we struggle to use correctly, and clinicians and patients should continue to focus on collaborative relationships that we can depend on Because, ultimately, it is about people, not science.
That’s my story and I’m sticking to it.