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How the Institutionalization of Medicine Has Destroyed the Doctor-Patient Relationship

As I reach the conclusion of an over decade-long training process to become an internal medicine physician, I find myself facing a dilemma I really did not expect. I am one of the few internists pursuing primary care and am hoping to build my own private practice.

Yet, while my training has prepared me to care for the sickest patients, I really don’t understand how to get paid for my work. The long and complicated medical training process does little to prepare young physicians for real world practice where a plethora of insurance, billing, documentation and pharmaceutical companies prey on naïve young physicians. Instead of teaching young doctors how to be independent leaders in their communities, medical training (pre-med, med school, residency, fellowship) remains stuck in archaic modalities of learning and communication, slow to adapt to modern technologies in a rapidly evolving world. As physicians complete lengthy training, we struggle to take our wealth of knowledge and experience to the community to build bonds to heal people, and instead we increasingly become frustrated employees with a diminishing role and no voice. The system is broken and we need current and future physicians to lead the evolution of health care.

Medical delivery is so fragmented with bureaucracy and specialization that both patients and physicians become exhausted attempting to traverse the convoluted landscape. We eventually take shelter in whatever comfortable scenario we can find, despite mounting frustrations with the breakdown of the doctor-patient relationship. The uncertainty and fear of rising and unpredictable expenses, coupled with loss of time and productivity, drive doctors to choose jobs within massive health care organizations rather than smaller private practices, despite the growing discontent with the loss of autonomy and choice in all aspects of patient care.

Patients and physicians so often share the same frustrations in this corporate medical environment. Short office visits due to overloaded schedules and unrealistic expectations push both doctors and patients to rush through issues instead of taking time to understand each other and build rapport. Increasingly redundant and burdensome documentation requirements drive a wedge, often in the form of a physical computer screen, between doctor and patient, further fracturing the bond. As physicians and patients try to choose the best treatment options, we soon find ourselves drowning in pre-certification forms, denials for payment and frustrating telephone conversations with insurance agents. The overly complicated system of billing and coding, marred with unfamiliar vocabulary, cumbersome paperwork and subtle legal complications, stands as a massive road block to physicians and patients alike and limits our ability to provide individualized care focused on each patient’s needs.

Instead of the the doctor-patient relationship, we develop relationships with health care systems which clearly lack the ability to provide compassionate, thoughtful patient-specific care. This depersonalization creates an environment full of inconsistencies, redundancy and dilution of responsibility. Patients become less trusting of their health care providers, as they watch the demotion of physicians from society leaders and forward thinkers to employees struggling to find their own way through all the muck.

A serious lack of leadership exists in the medical community with respect to political change and the public health agenda. Instead of coming together, we physicians remain fragmented in groups and organizations focused on either individual specialties or outsider interests. While the role of physicians in America’s health care delivery process becomes ever more narrow, I worry that we will have to watch the Headless Monster we have created ravage our society economically, emotionally and ultimately physically, if we do not mount a response. We must form a unified voice of reason that will help bring back the focus to the individual, their doctor and the delicate interpersonal relationship that is the pillar on which all quality medical care is founded.

As a medical student, it is important to realize how the industrialization of medicine will shape your future career. The large health care systems that dictate patient care nowadays also dictate how physicians are reimbursed and rewarded for their work. By this, I mean that payers want you to think that you need them more than they need you. If they can convince you of this, they can pay you less and get cheap labor in order to increase their bottom line and ultimately increase profits for them. The unnecessary rules and red tape limit our professional autonomy, eliminating the doctor-patient relationship that medicine was founded upon. Clearly, this comes at the expense of you and your patients. However, if we strive to treat patients the way they deserve to be treated — humanistically and uniquely — and to reestablish the real mission of our profession and what it truly means to be a doctor, then we can start to get our freedom back.

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5 Ways to Thrive in Your Medical Training

1. Practice with eyes wide open. Don’t let the system fool you. You’ll get many different, often contradictory, pieces of advice as you go through your training. The choices never end: which specialty to choose, how to study, where to practice, what to do with your free time. All of these decisions must come from a place inside yourself. Don’t let the “gunners” fool you into thinking you have to commit 100 percent of your time to studying. Don’t let the naysayers dissuade you from pursuing primary care specialties like internal or family medicine because the average income is less or that there is less associated prestige. The goal is to follow your heart regardless of anything else because a career in medicine is hard and if you don’t enjoy what you’re doing, you’ll end up unhappy in life.

2. Focus on your own health. Love yourself. People go into medicine, for the most part, to be of service to society and take care of other human beings in a meaningful way; however, this is impossible if you’re unhealthy and unhappy. Stay committed to your passion for sports, music, art or whatever else it may be. Don’t be fooled into thinking that if you sacrifice these things while you’re in medical school or residency, you can get them back later. You’re missing the point here. You’ll lose many, many years of potentially meaningful experiences and when the time comes to reintroduce these things back into your life you’ll find the struggle daunting. Remember that you set an example to every patient and colleague you work with intellectually, physically, emotionally and spiritually.

3. Do not make relationship decisions based on your training timeline. This one is tricky. You’ll often see that in 4th year of medical school many people get married. Why? Perhaps it’s because there is such an abundance of love, but I argue it’s actually because medical students have gone through a very trying time together and when it’s time to move away for residency, people are afraid to lose what they have gained. Take your time and realize that this is a long life and things will change. You’ll eventually finish training and you’ll be back to “the real world” where many other challenges await. There’s no need to rush into more commitments. Step back and don’t get caught up in the emotion of it all. Take your time with relationships. Remember, you can still Couples Match and not get married. It could save you much heartache down the road. Of course, this is easier said than done.

4. Never forget your mortality. Every single physician you work with is also mortal. We tend to venerate those older, wiser physicians above us because we strive to be in their position within the hierarchy of medicine. This is a remnant of the past, though. We’re all one big medical community and your teachers are struggling with the same issues you are. They too often have no idea what’s going on with the health care system or what’s coming in the near future. They too struggle with addiction, depression, isolation, fear, etc. Times are changing and it’s time for the younger generation to help lead the way in opening lines of communication about the psychological, emotional and physical stresses physicians face.

5. Most importantly, remember that each patient you encounter is an individual with varying needs and goals. Treat everyone with compassion and patience. Try to meet your patients’ needs instead of imposing your own ideas on them. In a previous article, I wrote about how we’ve dehumanized medicine and have essentially destroyed the doctor-patient relationship. It’s up to young doctors to try to repair this damage and focus on building rapport with patients in order to understand what they really need. Let go of the science and the recommendations for a moment. See the person sitting in front of you (yes, even put the computer down!). Help them find what they’re looking for when they come to see you. The interpersonal piece of medicine is where you’ll truly make a difference in someone’s life.

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