Changing
Doctor Patient Relationship: “Hostile Dependency Syndrome”
Summary: Violence against health care providers is widely
rampant and this has contributed to increasing cost of health care and added to
patients’ sufferings. Relationship between a doctor and patient is essentially
a relationship of trust and only this kind of relationship is in the best
interest of patients because of their limited understanding of medical
principles, practices and realities of the market place. Patients’ hostile conduct
towards their doctors has been described as Hostile Dependency Syndrome.
Hostile
Dependency Syndrome reflects normal dependence of patients upon their doctors
for their welfare, hostile conduct of patients towards their treating doctors
and the ensuing violent, arbitrary and illegal conduct of patients towards
their doctors.
Nature of
doctor patient relationship has undergone a profound change during later half
of last century and particularly during the last 4 decades. Patients are
becoming increasingly hostile towards their doctors. Mass media and judicial
acts have contributed in a great measure towards increasing hostility.
For media every
story involving doctor patient conflict is a hit and hot story wherein doctor’s
side of the story is often ignored and for individual controversies of doubtful
merits, entire profession is painted in black. I have rarely come across news
in which prima-facei allegations against the treating physician are made out. Their
sole motive is to sell their own publication and they know it well that such
stories are a hit among consuming masses. They are least bothered that such
biased reporting does no good to the subjects for whose cause they are
apparently fighting. This imbalanced, irresponsible reporting only increases
alienation of doctors from their patients and serves to strengthen the
invisible battle line between doctors and their subjects i.e. patients.
Judiciary
relying upon its authority under law of torts has adopted the robe of
legislature and redefined doctor patient relationship from a natural
relationship based on mutual trust to a legal relationship based on contract
for service. This effectively means that a doctor is duty bound to provide all
the services to a patient on demand but all the authority vests in the patient.
It includes duty to inform and the duty to procure informed consent from the
patient. It is the duty of the doctor to educate the patient about his clinical
condition and the treatment to be undertaken to such an extent that patient is
able to take prudent and pragmatic decisions before granting his consent.
Judiciary in their wisdom has completely ignored patient’s ability to
comprehend his doctor’s word. Moreover judiciary is completely oblivious to the
ability of a doctor to treat a patient upon whom he has no authority. A doctor
is legally required to protect his patient’s interests even in those situations
where patient acts arbitrarily, whimsical, idiosyncratic and in utter disregard
of his doctor’s advice. For example a doctor is supposed to provide discharge
summary even when patient leaves the hospital contrary to medical advice.
The traditional
and the natural view that doctor patient relationship is essentially a
relationship of trust , the treating doctor being the best judge of his
patient’s clinical condition and the treatment to be given, has been given a
good bye. Patients are no longer satisfied with the only right given to them
i.e. right to select their doctor. Patients no longer feel that they are duty
bound to comply with their doctor’s advice.
Majority of patients in exercise of their right to personal satisfaction
think that they have a free will and no rule of conduct applies to them but at
the same time they expect a doctor to be bound by ethics, morals, law and at
the same time be able to or is rather duty bound to cater to all their
individual interests, whims, fancies, wild and weird ideas. Patient would not
hesitate to call themselves as customers and even law has recognized them as
consumers. Doctor’s legal liability towards his negligence has been blown out
of proportion. Patients often levy wild allegations and thus harass doctors
before various legal and administrative forums even when their allegations are
ambiguous and lacking in particulars of alleged negligence.
Increasing
hostilities have led to alienation of doctors from their patient’s welfare
which is reflected in refusal to attend odd hour calls and majority of doctor’s
children opting for a profession other than medical profession (According to
one survey 85% of doctors children do not want to become doctors). Doctors
often agitate in pursuance of their demand for increased security. Hospitals
have employed bouncers to keep trouble mongers off. In one Indian state, many
doctors keep arms and ammunition in their clinics for the purpose of personal
security.
Hostilities and
unreasonable conduct of patients and their attendants have led to a vicious
cycle wherein doctors are progressively becoming more commercial and
manipulative whereas patients are becoming more hostile. Clinical acumen based
practice has given way to scientific and legal evidence based practice in which
instead of patient welfare, the doctor’s preoccupation is being on the right
side of law irrespective of cost of treatment to the patient. This has made
healthcare very expensive and unaffordable for the great majority. Hence in
USA, these days there is talk about Obama Care.
Nature of doctor patient
relationship: It is essentially a relationship
of trust. The reason being that no human being in his capacity as patient have
sufficient knowledge and experience to be able to determine the best for him
and choose and demand accordingly. His treating doctor is the only person
competent to do by virtue of his education, cumulative experience, knowledge,
skills and management practices. It is
not possible to lay down law and legal procedures to meet vast diversity of
situations any doctor encounters in his medical practice. Therefore, for his well
being patient is squarely dependent upon the treating doctor. Under these
conditions, nature of relationship demands that patients must be modest while
dealing with their doctors so as to draw maximum benefit out of cumulative
experience of the attending physician. In this situation, the only right that
can be granted to a patient is the right to select his doctor and this right
has already been granted to all the patients. But once a patient has chosen a
doctor, he is bound to comply with his doctor’s prescription in his own
interest and is bound to pay fee for services rendered. In my medical practice,
I have seen that even the most intelligent of patients are rarely in a position
to control and regulate management of their clinical condition.
Doctor’s perspective: Medical practices demand a holistic approach and
require a doctor to utilize his total experience for the benefit of each and
every patient. There are no stereotyped responses. Best medical practices have
evolved over a period of 2000 years and are beyond a patient’s common sense. A
doctor demands compliance of his prescription and fee for the services
rendered. Doctor’s only concern is clinical condition of the patient and its
management. A doctor can’t refuse treating a patient on grounds of personal enmity
or likes and interests. In the great Indian epic Ramayana, Ravana’s personal
physician Sushain was called upon to treat his opponent Laxman and Sushain
never refused.
Acts of a doctor
are often amenable to peer-review but no member of judiciary, bureaucracy or
legislature can ever be competent to judge a doctor’s acts or prescribe conduct
rules for doctors. To extract the best out of a doctor, a patient has to be
modest and comply with his prescription and be ready to pay fee for the
services rendered. Trust, modesty and compliance are the 3 cardinal principles
for patients to better connect with their doctors. Quite often doctors
encounter patients seeking free consultation for one or the other reason and
employ all sorts of tools and techniques to achieve their ends. But little they
realize that this is the beginning of doctor patient conflict.
Patient’s perspective: Patient often tend to think that doctors are just
like any other businessman or service provider working in accordance with
profit maximization theory of a firm. Accordingly patients don’t hesitate to
regard themselves as consumers or customers of the attending physician.
Patients not only exercise discretion in selection of their doctors but also
pass all sorts of value judgments about their doctor. They will interfere at
each and every step of the way. Patients often demand doctors to satisfy their
illegitimate and illogical interests, whims and fancies. On one hand they would
elevate a doctor to the level of God and the next moment they can be seen
indulging in reckless violence against their doctors. Patients generally have a
very poor idea of medical practices and realities of market place but want to
dictate themselves under the pretext of seeking satisfaction, at times only
because they are paying the money.
Because of wide
gaps in perception of doctors and patients, conflicts are inevitable and hence “Hostile
Dependency Syndrome”.
Hostilities
against health care providers at all levels of social hierarchy have led to a
shift from clinical acumen based medical practice to scientific and legal
evidence based practice. In the former, for a doctor, patient’s welfare is
supreme whereas in the later being on the right side of law is the supreme
consideration. The later approach not only makes healthcare extremely expensive
and unaffordable for majority of the patients but also acts contrary to
patients interests in so many ways.
So the best
approach for a patient is to establish a relationship rooted in trust so that
the attending doctor feels responsible for his patient and makes his best
efforts to restore his patient’s health. But hostile attitude, raising
unreasonable demands or indiscriminately exercising his rights and
opportunities is clearly counterproductive. I have seen patients hurting
themselves more often by their own negligence rather than negligence on the
part of their doctors.
It is against this backdrop that http://curatio.in has been founded in order to help patients in taking
informed decision in the matter of selection of their health care provider and
reap the greatest benefit out of his cumulative experience. It is sincerely
expected that this initiative would improve doctor patient relationship leading
to decline in incidence and prevalence of Hostile Dependency Syndrome.
Author: Dr Mahesh C. Jain is a practicing
medical doctor and has written the book “Encounter of Science with Philosophy –
A synthetic view”. The book begins with first chapter devoted to scientifically
valid concept of God and then explains cosmic phenomena right from origin of
nature and universe up to origin of life and evolution of man. The book
includes several chapters devoted to auxiliary concepts and social sciences as
corollaries to the concept of God. This is the only book which deals with
origin of nature and universe from null or Zero or nothing.
http://curatio.in
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