Withering trust: Redefining the doctor patient relationship

摘要

The relationship between the doctor and patient has been defined over the last 2500 years or more. It is unique as it depends entirely on honesty and trust between the two parties. Until very recently, doctors were held in high regard by society in general for their knowledge, compassion, and ability to alleviate suffering, helping when men and women were at their most vulnerable.[1] This relationship had matured to be of mutual benefit, but of late, it has changed to adopt new norms – norms that society is still struggling to keep pace with. So, what exactly has changed? One of the first and foremost things that has changed is the access to information. Even at the turn of the millennium, medical knowledge was confined to the doctors who would treat patients who, in turn, had little or no knowledge of the disease. Explanations would be brief, if at all, and questions would often meet with a terse reply. Patients themselves would visit the doctor who had been recommended and, for fear of offending, who would keep quiet and suffer in silence. But the internet changed all that – the access to unlimited information allows patients to be more informed about their disease such that they can ask far more relevant questions than they have ever in the past. Some doctors may find this to be an affront to their knowledge and that is where the problems often start. Armed with unsubstantiated information from the internet, which a lot of patients believe to be Gospel, they may have unrealistic expectations of treatment. In the absence of communication and pertinent counseling between the patient and the doctor before the commencement of care, things can very rapidly spiral out of control, despite adequate treatment. The other major change that has happened over the last 50 odd years is the cost of providing health care. When the National Health Service in the United Kingdom was founded after World War II, by Sir Aneurin Bevin, it was widely believed that once the health of the nation of 50-odd million improved by the implementation of good primary health care, the hospitals would have lesser patients and the cost of health care would reduce. Today, we know how far from the truth that assumption was. Medical care can now treat more than it ever did, using tools that would be considered science fiction a few years ago. Medicines that are manufactured in large establishments set up to the highest standards of hygiene and safety treat a far wider spectrum of ailments than we ever did in the past – a far cry from the mortar-and-pestle compounds of 50 years ago. The newer compounds and devices themselves are subjected to rigorous clinical trials that are by-and-large funded by private companies who demand a return on their investment. The diagnostic space is also rapidly expanding. The humble X-ray and ultrasound have now given way to the CT and MRI scans that are able to give us not only high-quality structural data but functional data as well. These machines are technology-driven and very expensive with a very limited life span; everchanging technology results in need for replacement every few years. The scalpel has given way to the laser, microscopes, endoscopes, and robots – all expensive tools to shorten hospital stay, enhance patient experience, and improve patient outcome. Not just the cost of providing health care but the cost of acquisition of medical education, postgraduate and specialty training, often in privately run medical colleges, has also spiraled out of control and is proportional to the number of years invested in it. Once qualified from these institutions, a proportion of doctors look to redeem costs. Unfortunately, this has given rise to an everincreasing “kickback” practice, where “cuts” are offered for referral of patients, or for their investigations.[2] All this has further corroded the reputation of the doctors, even though the vast majority are honorable, conscientious, and empathetic who treat their patients ethical