Protecting the Doctor-Patient Relationship

When a patient chooses a doctor they form a sacred trust that together they will pursue the best diagnostic and treatment options available to meet the individualized goals of the patient. This trust, the essence of the doctor-patient relationship, charges each doctor to properly utilize the tools at his disposal and never to relent until the absolute best care is given. Most of us went into Medicine to honor this relationship, and serve our patients at all costs. And, interventional cardiology, with its strong use of personal, cognitive and technical skills over oftentimes years of direct patient care, has allowed us to form some of the most powerful and constructive doctor-patient relationships of all.

But this, the heart and soul of the individualized practice of Interventional Cardiology, and Cardiology in general, has been increasingly challenged and may be reaching a critical point with health care reform.  Although all fields of Medicine will be targeted, the greatest focus has been on curtailing cardiovascular disease-related expenditure. Thus, as an interventional cardiologist, I now have not one (i.e. the patient) but several bosses. Professional societal practice guidelines, private insurance company regulations, and government insurance (i.e. Medicare/Medicaid) mandates all seek to modify how we treat our patients, outwardly in the name of quality, but also unabashedly in the name of cost.  And hospitals have had to learn to survive too, imposing their own policies on us.

As interventional cardiologists, we increasingly must defend our actions to insurance companies, be it when ordering a nuclear stress test or prescribing (or not prescribing) medications.  We speak to insurance company-employed physicians as part of a peer review process several times per week, sometimes convincing them of the wisdom of our decisions and sometimes not.  Once in the hospital, we must abide by appropriate use criteria for percutaneous coronary intervention (PCI), even though not all scenarios are addressed by the document, and not all patients would make the same value judgments.  We make sure all patients with acute myocardial infarction and congestive heart failure are prescribed all the right medications on admission, and that door-to-balloon times are always less than 90 minutes, so that we exceed Medicare value-based purchasing targets.  We prioritize minimizing length of stay, including not admitting patients with several co-morbidities who insurance companies tell us can be safely observed for a few hours after a moderately-complex PCI instead.

With all these mandates going through our heads, it is easy to see why doctors may feel as if they are the only ones watching out for the patient, fighting for their rights in a system that increasingly looks at populations and disease states instead of the very unique individuals themselves, and values cost more than perfection or individualized care. Since we are paid by insurance companies, and not by the actual patients, the doctor-patient relationship and, indeed, the patients themselves, may be inadvertently demoted in priority, as physicians subconsciously see the insurance companies, hospitals, and Medicare/Medicaid as the bosses to whom they need to answer.

Now, it is also easy to understand why this has come to pass. Doctors, in their zeal, have not prioritized cost containment and appropriate resource utilization, and have often thought that more is always better for their patient.  If more testing can increase the sensitivity of finding the problem, and thereby finding a solution, then why not do it? If a procedure can improve symptoms, even marginally, why not do it? Our boss was always our patient and the only one we needed to prioritize, until now.

As the pendulum swings towards health care reform, with an eye towards cost containment, we must never forget that we remain the only ones who can protect our patients and the sanctity of the doctor-patient relationship.  Yes, we as a profession are guilty of charging ahead and perhaps over-ordering, over-diagnosing, and even over-treating at times, but so too have we under-ordered, under-diagnosed, and oftentimes under-treated. We must not be made to feel guilty for the extravagance of patient care our system allowed, only to have that guilt keep us from defending the one part of that system we held dear. We must continue to advocate for the rights of our patients and our rights as their physicians.

To this end, both the Society for Cardiovascular Angiography and Interventions (SCAI) and the American College of Cardiology (ACC) have launched campaigns to empower our roles as patient advocates.  Within the Society, we must defend PCI and other procedures for the benefits they confer and the options they give our patients.  And, within the College there is interest in promoting a sense of “patient-centeredness”, partnering with patients and thus doing on a field-wide level what the doctor-patient relationship has always charged us to do on an individual level.

The challenge will be how best to navigate the slew of mandates and regulations, disproportionately loaded onto our shoulders, without sacrificing our patients’ best interests and the sanctity of the doctor-patient relationship that has always been the linchpin of US healthcare.  How do we stand up for physician-patient autonomy and choice, while still minimizing cost and excess on a national scale?  In effect, how do we protect the one thing we went into Medicine for?  I do not have the answers, but I do know the dialogue must begin, and I am pleased that our professional societies feel the same way.

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This month’s contribution to Invasive Thoughts was written by Srihari S. Naidu, MD.  Dr. Naidu is Director of the Cardiac Catheterization Laboratory, Interventional Cardiology Fellowship Program and Hypertrophic Cardiomyopathy Treatment Center at Winthrop University Hospital on Long Island, and Associate Professor of Medicine at SUNY – Stony Brook School of Medicine. He is a Trustee of the Society for Cardiovascular Angiography and Interventions (SCAI) and Appointed Member of the American College of Cardiology Cardiovascular Leadership Institute (ACC-CLI) and Interventional Scientific Council (ACC-ISC).