Patient's Orders: How Information Technology and the Media are Changing the Patient-Doctor Relationship

A NextGen Free-Standing Perspective Article

http://www.nextgenmd.org/vol3-7/patients_orders.html


Like the game of "playing doctor" in which children "examine" and prescribes "treatments" to their teddy bears and toy bunnies, the prevailing view for much of medical history has been to relegate patients to a passive role, quietly accepting orders as the stuffed animals do. The explosion of the availability of information, however, seems to have breathed participatory life into patients. The maturation of the World Wide Web has especially altered the information landscape. Suddenly, "Mr. Bunny" and "Ms. Teddy" not only have more knowledge, but also have consequently realized that they can demand specific treatments or even shop for physicians. Despite the disagreements over the effects, the complex patient-physician relationship has certainly been shifted. The modern physician, in seeking to counter-balance the monetary or political pressures exerted by outside groups and consumer misinformation, should be careful not to overlook the benefits that opening up dialogues to patients and regulators could bring.
It seems self-evident that "Better health...was consistently related to specific aspects of physician-patient communication."[1] The behaviors of both the patient and the doctor are inevitably determined by human psychological responses: conversation tone, mannerisms, eye contact, appearance, and other non-technical aspects of a physician consultation strongly impact the patient's view of the physician. These details ultimately contribute to the patient's adherence to a doctor's prescribed treatments. One study found a positive connection between robust doctor-patient interaction and patient health, with the impact particularly strong for the initial meeting–the theory is that the initial meeting is especially important for the patient, who is more likely to take into account the physician's style and appearance in evaluating "trustworthiness."[2]
In one of the first studies of the social role of physicians, the doctor is found to be customarily viewed as "complementary" to the patient. Physicians are expected to maintain confidentiality and act only in the interest of patient well-being, thus earning the confidence of the patient's personal details.[3] The professionalism and autonomy of physicians is expected by patients, who otherwise would have more difficulty revealing intimate medical and personal histories. The approach to which a physician takes towards a patient also determines the level of willingness a patient has in revealing information and following the physician's advice.
For the purpose of studying consultation interactions, the exchanges have been generalized as "doctor-centered" or "patient-centered." Traditionally, physicians using a doctor-centered approach ask directed questions for specifics about the patient's disease, focusing on the objective and treatable aspects of the disease. A "patient-centered" approach uses more open questions that leave the patient with broad range to describe general feelings and background, with participation on both sides more like a discussion. While this approach consumes more time, physicians are able to understand better the patient's past history, personal views and priorities on the disease or treatment as well as other social, cultural or economic sensitivities, allowing the physician to be more flexible to accommodate the patient's beliefs. A survey of nearly 8,000 patients and 300 physicians found a significant improvement in patient satisfaction and retention among physicians who used a "participatory" style of discussing options and learning patient preferences over those physicians with more controlling styles.[4] The cost in time of a longer visit could potentially be outweighed by reduced future visits due to more effective treatment and adherence. Indeed, the increasing use of electronic files and handheld computers (PDAs) has helped physicians recall vital details in patient files. [5]
Patients may enter with false preconceived notions gained through hearsay, the media or the Internet. With the advent of millions of websites, patients can search online for their symptoms and approach the physician with their own opinions concerning diagnosis and treatment. A myriad of websites falling on a spectrum in accuracy offers information on nutrition, self-diagnosis, and diseases, prompting patients to come to a physician with concerns. A search on the web for vaccination quickly reveals well-run, professionally designed sites dedicated to marketing the dangers of vaccination. These web pages feed the hype and fuel public fears by altering statistics, focusing on the rare instances of adverse reaction, or outright fabricating stories that promote avoidance of vaccines. In recent vaccine efforts, such as the smallpox vaccine, widespread media coverage and public outcry followed isolated cases of adverse reactions. In reality, in the US, the vaccination program has generally been successful, with over 90% of schoolchildren receiving vaccines for many diseases. In 2005, the number of measles cases in the US doubled in part because the disease "was imported into a population of children whose parents had chosen not to vaccinate their children because of safety concerns, despite evidence that measles-containing vaccine is safe and effective." [7]
In recognition of the power of media over patient views concerning healthcare, the government has created comprehensive websites for patients, doctors, and administrators as factual references. The Centers for Disease Control has established a team of scientist consultants in Hollywood to help television and movie producers generate accurate representations of illnesses and increase awareness of the need to receive testing and treatment for diseases like HIV/AIDS. As a result, a decrease in myths and misconceptions concerning HIV, SARS, and influenza being broadcast to the public has been noted, and calls to information hotlines have surged following strategically placed commercials on shows. [8]
Another facet of the Information Age is the direct marketing of drugs to patients. With the popularization of direct to consumer marketing of pharmaceuticals in the US following the 1987 Prescription Drug Marketing Act, the majority of patients have been exposed to pharmaceutical commercials that aim to boost sales of drugs for certain conditions. An industry analyst estimated advertising spending upwards of $15 billion on prescription drugs in the US in 2002, with almost a third of the pharmaceutical workforce dedicated to sales and advertising. [9] The impact is clearly heightened awareness of selected conditions. In an FDA survey, 60% of patients say advertisement for drugs help create better discussions with doctors, and 27% percent claim a drug advertisement caused them to ask a physician about a condition that had not been previously discussed. [10] Much like how the Internet has facilitated patients obtaining knowledge, consumer-directed medical advertisements provide another weight in changing the traditional balance of physician-patient interactions. Recently, the right of a patient's to his or her own preferences, versus a physician's judgments, has become an issue influenced by the debate over the potency of advertisements. With the responsibility of patient-physician interaction at stake, debate over restrictions of advertisements and formulation of regulations such as informed consumer consent seem inevitable for the foreseeable future. [11]
Finally, the information presented online has begun moving beyond medical issues to include physicians and facilities. The cost of healthcare has continued to rise tremendously, exceeding two trillion dollars in the US in 2005. [12] With this substantial burden, private industry and public legislators have begun to rethink traditional views concerning medicine. One initiative involves making available online the prices and ratings of doctors and hospitals, letting patients become market-based consumers and physicians become economic goods, hoping that patients will choose less expensive doctors and treatment options. For example, certain insurance companies have chosen this approach, complementing it with high deductibles and co-payments to ensure "consumer-driven" health care and awareness of the true costs of healthcare purchases. In addition to shopping between physicians in the domestic market, patient-consumers - albeit a small minority - are venturing overseas for treatments too costly or not permitted by their physician in the US. So-called "medical tourists" are encouraged by their employer or insurer to travel abroad to undergo surgery or treatment at a fraction of the cost of treatment domestically. The impact of off-shoring certain procedures on physician-patient relationships and the health of patients has not been extensively studied yet, but doubtless holds ramifications for the medical profession.
The physician-patient relationship has evolved with changing technology and increased pressures from various outside groups. Whether it is through more open, conversational interaction or more directed questioning, physicians have been modifying their techniques and mannerisms to fit the sign of the times. Indeed, in the future when perhaps advanced diagnostic tools and computers can pinpoint precise disease symptoms, the physician-patient interaction will continue to be key in developing holistic approaches to better health.

Emory Hsu is a writer for the Next Generation and a member of the Harvard class of 2008.

Work Cited

1. Kaplan S, Greenfield S, and Ware J. Assessing the Effects of Physician-Patient Interactions on the Outcomes of Chronic Disease. Medical Care. 1989: 27(3) (Supplement):S110-S127
2. Heszen-Klemens I and Lapinska E. Doctor-Patient Interaction, Patients' Health Behavior and Effects of Treatment. Soc. Sci. Med. 1984 19 (1)
3. Parsons T. The Social System. Glencoe. 1951.
4. Kaplan S, Greenfield S, Gandek B, Rogers W, and Ware, J. Characteristics of Physicians with Participatory Decision-Making Styles. Annals of Internal Medicine. 1996, 124 (5): 497-504
5. Martin S. More than half of MDs under 35 now using PDAs. Canadian Medical Association Journal; 2006 169(9):952.
6. Borders T, Xu KT, Heavner J, and Kruse G. Patient involvement in medical decision-making and pain among elders: physician or patient-driven?. BMC Health Services Research; 2005: 5:4
7. Morbidity and Mortality Weekly Report December 22. US Centers for Disease Control; 2006; 55(50):1348-1351
8. CDC helping TV show writers keep the medicine real. April 2007. Associated Press.
9. The Other Drug War. Frontline, PBS/WGBH-TV. June 2003.
10. FDA Division of Drug Marketing, Advertising, and Communications.
11. Epps PG. Direct-to-Consumer Marketing: A Need for Informed Consent in Drug Therapy? Abstr Academy Health Meet; 2003
12. Catlin C, Cowan S, Heffler et al. National Health Spending in 2005. Health Affairs; 2006; 26(1) : 142-153