Calling the Shots: Doctor/Patient Relations in the United States

Thesis Prospectus: I am studying patient-centered medicine in the United States from the 20th and 21st centuries because I want to find out how treatment decisions are made in order to understand the balance of opinion between doctor and patient. Thesis Statement: A good doctor will use his training and experience to find a diagnosis or treatment plan that the patient is comfortable with and feels is the best choice for them based on their beliefs, instincts and other factors including trust and where they get their information from.

Erica Ellis HIS 475: Topics in Medicine, Culture and Values Topic: In Sickness and in Health: Cross-Cultural Approaches Professor Wilson April 26, 2012

When someone goes to the doctor one of two things are happening. Either it is a routine check-up like an annual physical or the person has experienced some sort of change or pain with their body and they are looking for answers. This could be a trip to their primary physician or their third opinion this month. Somehow, the person feels that something needs to be done and is calling on the doctor, as a professional, for help. Depending on the philosophies of both the doctor and the patient, a conclusion can be reached that makes both feel safe and happy. A good doctor will use his training and experience to find a diagnosis or treatment plan that the patient is comfortable with and feels is the best choice for them based on their beliefs, instincts and other factors including trust and where they get their information from. Patient-centered medical treatment is a model that focuses on achieving the proper balance between doctor and patient. Patient-centered care is a phrase first coined in 1969 by British psychoanalyst Enid Balint.1 True to its perceived definition, this type of medical care seeks to address the patients concerns and needs over the doctors biases.2 This type of treatment mixes the patients personal medical history with their concerns about procedures and treatments and what they feel are their needs. In this system, the opinion of the person being treated is held in higher esteem than the one doing the treating. This moves away from a system in which doctors treat all people with the same symptoms the same way. This gives the patient a sense of control in their lives. Charles L. Bardes, M.D., Defining Patient-Centered Medicine, The New England Journal of Medicine 366, no. 9 (March 2012): 782. 2 Ibid.
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A person wants to feel they have their lives in control and that they are doing what they need to do to stay healthy. Part of this feeling comes from knowing that something is wrong and seeking the help or treatments necessary to combat the issue. As people and as patients, humans have a need to know and will push to find a diagnosis. Once they have found a diagnosis, they can feel at ease about treating it so much so that knowing their issue has a name can almost act like a placebo.3 Once a person is aware that their condition has a name, they can then choose how, or if, they want to treat it. But these choices are the patients to make. A patient feels that something is wrong, so they choose to go to the doctor. They push for answers and get as many opinions they want until they feel comfortable with what is happening. They ask their general doctor for recommendations to go see specialists. Doctors can ablidge out of their own curiosity or the industry dollar signs in their eyes, but either way, the patient is doing things they want to.

Patient-centered care thrives properly in an environment where a person has faith in their doctor and their methods. According to Gallup Poll results from 2002, 61% of Americans have a great deal of faith in their health care provider.4 Though this number seems like a success for those working in the medical industry that leaves slightly more than one out of every three people lacking confidence in their doctors abilities to help them. Those who do not trust their doctors may be Lynn Payer, Disease-Mongers: How Doctors, Drug Companies, and Insurers Are Making You Feel Sick (John Wiley & Sons, 1994), 21. 4 Gallup, Americans Rate Confidence in Doctors. http://www.gallup.com/poll/7369/americans-rate-confidence-doctors.aspx (accessed April 11, 2012).
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susceptible to believing they have illnesses illustrated by the media or that something bigger is happening other than their doctor is leading them to believe. However, they may also be active enough to pursue other opinions and as a result, a more accurate diagnosis. According to a study done by the Mayo Clinic from 2001 to 2002, the traits a patient wants to see in their doctor are confidence, empathy, humanity, personable, forthcoming, respectful and thoroughness. When evaluating whose opinion carries the most weight in a medical decision process personable, respect and thoroughness become key. People will trust a doctors treatment plans or ideas if the doctor shows consistent persistence for the answers and takes the initiative to understand the patient and what they want. Taking the patients beliefs, thoughts and fears into consideration is the only way to successfully diagnose and treat any illness.5 Some medical decisions fit better with the patient-centered model than others. Women choosing what kinds of birth control they wish to take have much more freedom than someone who is trying to combat stage four cancer. Women can choose from a range of types of birth control such as oral contraceptives, intrauterine devices or shots and even the brands and specifics that surrounds those medications. This can be done for budgetary reasons, person belief about one type, experience and testimonial from friends or even why they wish to take it and how far into the future they wish to be using birth control pills.

Miranda Hitti, 7 Key Traits of the Ideal Doctor, WebMD, http://www.webmd.com/healthy-aging/guide/20061101/7-key-traits-of-idealdoctor (accessed April 11, 2012).
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Wondering how to treat cancer does not leave someone with many options. A sense of urgency to make tough choices and the concerns with such a fatal illness can make it difficult to have an array of choices, which decreases the chance that the patient is comfortable with the treatment plan. When it comes to choosing birth control a woman has hundreds of options, and only one is to not do anything. Not doing anything is one out of possibly 3 options when it comes to cancer. And sometimes, a patient feels automatically pressured to take action out of fear.6 When someone feels that their doctor is not properly addressing their condition or is leaving something out, they may go elsewhere for other opinions. Although these gutsy quests for answers can sometimes reveal a diagnosis that a general doctor could not find or did not have the inclination to look for, it can also be a trying time for a patient if they go through trial after trial and come up empty handed. The rationale behind patient driven care may come from a self-serving place on the part of the doctors. Marketing of drugs, and the industry that is medicine, thrives on people spending money for treatments, whether they need them or not. Even for ulterior motives, doctors allow patients to pursue their own medical futures. If a person believes, without their doctor, that they have something wrong with them, they will pursue it deeply. The cost of this relentless pursuit to the individual can be high if they do not trust their physician and ask to see more doctors for opinions and specialists. If they do trust their doctor, they can feel safe in that opinion and stop looking. But where do these ideas of illness come from? The (Levitin 2011), Whats the Alternative? The Worldwide Web of Integrative Medicine, The New England Journal of Medicine 366, no. 9 (March 2012): 783.
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medical industry puts out on television ads for cures to illnesses that some people have.7 However, if someone sees the commercial and feels afraid they may have it, they can go talk to their doctor and find out for sure, but at the price of an office visit and perhaps a prescription if it turns out a person does have the condition. Regardless of whether a person leaves with a clean bill of health and accepts it, a desire for a second opinion or a new prescription, that individual took the initiative to get it checked out on their terms. Sometimes the patient discovers something they would not have known about their health, or they turn out to be ok and go about their lives. That is how we know that the patient calls the shots in todays medical world. One of the greatest examples of how patients really do make the choices when it comes to their medical care is how orthodox versus alternative medicine has been perceived in recent years. In the beginning of the 20th century both orthodox and alternative medicines had followings in the United States but by the 1930s there had been a clear shift toward orthodox procedures on the part of patients.8 Recently, people are opting for alternative, holistic treatments instead of, and sometimes, in addition to orthodox medicine. A passage from the review of Your Medical Mind in the New York Times articulates this phenomenon perfectly. Groopman and Hartzband [the authors of Your Medical Mind] explore two sets of biases that affect patient decisions. We can be minimalists, preferring to do as little as possible, or maximalists who aggressively pursue treatment. This process of convincing well people that they are sick is coined by Lynn Payer as disease-mongering. Payer, 5. 8 Hans Baer, Biomedicine and Alternative Healing Systems in America: Issues of Class, Race, Ethnicity, and Gender (2001): 31-32.
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We can be technology enthusiasts, seeking the newest drugs or procedures, or naturalists who believe the body can cure itself, perhaps with the aid of spiritual and plant-based remedies. Of course, these orientations interact: anyone who lives in Northern California knows someone who eagerly takes armloads of herbal supplements while having their chi realigned in between weekly acupuncture sessions (maximalist--naturalist). And there are minimalist--technologists, who avoid medical treatment when possible but if surgery is required will ask for the latest high-tech robotic laser surgery.9 As illustrated by these examples, the route a patient takes in their treatments and overall wellness comes from themselves primarily and their beliefs and views on medicine. Ultimately, if a person does not feel sick or compelled to believe they have a disease, they will not go to the doctor. Whatever the reason may be, it is still their choice. Whether they trust their doctor, their gut or the ads on television, as patients of the health care system in the United States should take matters into their own hands.

Daniel J. Levitin, review of Your Medical Mind: How to Decide What if Right for You, by Jerome Groopman and Pamela Hartzband, The New York Times, October 7, 2011. http://www.nytimes.com/2011/10/09/books/review/your-medical-mind-byjerome-groopman-and-pamela-hartzband-book-review.html?_r=2 (accessed April 23, 2012).
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Bibliography
"Americans Rate Confidence in Doctors." Gallup. 2002. http://www.gallup.com/poll/7369/americans-rate-confidence-doctors.aspx (accessed April 11, 2012). Baer, Hans. Biomedicine and Alternative Healing Systems in America. Madison: University of Wisconsin Press, 2001. Bardes, Charles L. "Defining "Patient-Centered Medicine"." The New England Journal of Medicine 366, no. 9 (2012): 782-783. Hitti, Miranda. "7 Key Traits of the Ideal Doctor." WebMD. March 9, 2006. http://www.webmd.com/healthy-aging/guide/20061101/7-key-traits-of-idealdoctor (accessed April 11, 2012). Levitin, Daniel J. "Review of Your Medical Mind: How to Decide What is Right for You by Jerome Groopman and Pamela Hartzband." The New York Times. October 7, 2011. http://www.nytimes.com/2011/10/09/books/review/your-medical-mind-byjerome-groopman-and-pamela-hartzband-book-review.html?_r=2 (accessed April 23, 2012). Payer, Lynn. Disease-Mongers: How Doctors, Drug Companies, and Insurers Are Making You Feel Sick. John Wiley & Sons, 1994. Srivastava, Ranjana. "What's the Alternative? The Worldwide Web of Integrative Medicine." The New England Journal of Medicine 366, no. 9 (March 2012): 783.