What is a doctor-patient relationship?

I had a pediatrician when I was a kid. Dr. Keefe. He was my mom’s go to. He was in a solo practice in St. Charles, MO where I spent the first 22 years of my life. Then I moved to Pennsylvania to go to med school. Ever since, I’ve never had a “relationship” with a primary care doctor. Granted, I’m a doctor. I can prescribe my own meds or go see my doctor friends. But, in talking with friends and family, I occasionally stumble across someone who uses the term “my doctor.” It’s like they’ve somehow seen and befriended a mythical creature.

If you do a literature search for “how many people in America have a relationship with a primary care doctor” you get zero results. First of all, nobody would benefit financially from the results of the study, so nobody would spend time and money on this issue. We know what people are. We know what primary care doctors are. But we don’t know what “relationship” means.

So what the hell is this mythical thing?

First and foremost, a relationship is loyalty to someone you respect, trust, and jives with your personality. In order to find that one person, just as you find a spouse, you’ve got to shop around and experiment to find the one that actually personally fits with you. This is a rare find.

Second, we’re a mobile society, both doctors and patients.

Doctors move neighborhoods. Doctors move jobs. And doctors move health insurances they take. Doctors are increasingly no longer solo entities. They’re now part of group practices that have been bought up by local large hospital networks. Doctors are becoming employees, not entrepreneurs. They’re abandoning the personal responsibility felt when you’re emotionally, professionally, and financially beholden to the group of patients you’ve been building relationships with for years.

And people move neighborhoods. People move jobs. People move health insurance companies. If they move too far away from “their” doctor, they have to find a new one. And when their doctor takes a job at a large group practice, the group has to provide a better experience and benefits than the solo doctor. If not, the patient will likely lose loyalty. They’re often forced to lose loyalty because the average person changes jobs every two to three years. And when they change jobs, they are almost guaranteed to change health insurance plans. Even when they stay in their job, companies change health insurance plans every few years because health insurance has become a race-to-the-bottom commodity. And every time you change your plan, there’s a good chance “your” doctor won’t take your new plan.

Compounding all these logistical issues, the way different age groups consume healthcare has more to do with the demise of the old-fashioned doctor-patient relationship than anything. As children, we get sick and hurt all the time precipitating many acute visits. We also have a very set schedule for why and when we’re supposed to visit the pediatrician to keep everything all up to date. Then, blam, high school and college happens. Then our 20’s. We don’t need much healthcare in our 20’s and 30’s except for the same kinds of issues we had when we were kids- acute sickness and injuries. But we’re too old for our pediatricians and we also feel out of place sitting in waiting rooms with 90 year olds. For the most part, 40’s and 50’s are the same, except some of us start having an early onset of old people diseases. Then our 60’s happen and the diseases we get tend to mimic more of a 90 year old than a 10 year old. And that’s when we again start looking for the old-fashioned close relationship with an internist similar to the one we used to have with our pediatrician.

All relationships, both personally and professionally, are built over time with consistency and mutual dedication. Does it qualify as a relationship if you’ve seen a doctor 3 times over 3 years? How about if when you make an appointment at your doctor’s practice and her colleague sees you because your doctor had to leave early that day? How long must the loyalty and consistency exist before we can call it a relationship? One year? Two? Ten? How many visits? And does it matter what those visits were for?

Kids need a consistent pediatrician. The elderly need a consistent internist. The chronically ill, no matter the age, need a consistent team and place to receive care. But for the rest of us (around 75% of the population) the likelihood of wading through today’s nearly impossible logistics of maintaining consistency and mutual dedication makes this old-fashioned thing called a “doctor-patient relationship” unrealistic in today’s society. And honestly, how much of a relationship can you build with a doctor when the interaction is a harried 8 minute conversation in which your doctor is constantly interrupting to focus your answers to her questions. Not only is it unrealistic, it’s of questionable value. I’ve heard it said that the value of longitudinal healthcare data, which is what a relationship is supposed to maintain, is less valuable the older the data. Data that’s 5 years old is less valuable than data that’s 5 weeks old. Since from your 20’s and into your 60’s most people need more transactional fixes than ongoing routine management of issues, the value of the data and the emotional connection you have with your doctor simply isn’t there.

Going forward, we need to update the definition of the doctor-patient relationship. We need to view it as a tool meant to solve a certain constellation of problems for a certain kind of person. But as we all know, there is no one tool  to solve every problem. And we also need to stop assuming that everyone has a relationship with a primary care doctor. Our data here at Sherpaa suggests that only 10% of the working age population does. And we also need to stop saying that everyone needs a relationship with a primary care doctor. Not everybody does. Anything that’s threatening to the concept of the old-fashioned doctor-patient relationship doesn’t need to be feared. A relationship with a singular doctor is a wonderful tool to solve a certain subset of health problems for a certain type of person. Not everyone has that subset of problems. Marcus Welby was a wonderful invention for a certain time when things were less complicated and less mobile. Times have changed and he’s no longer the perfect tool for every single healthcare problem.