June 10, 2008

Provider-side issues in physician-patient relationships

Rahul K. Parikh is a doctor and writer for Salon. He recently wrote and article for the New York Times concerning the ability and ethics of a doctor rejecting people as patients. Parikh emphasizes that his situation is not about directly denying provision of care:

The physician-patient compact basically states that a doctor will care for a patient in exchange for compensation and that the patient will heed the doctor’s advice. Patients who disagree with their physicians, or just dislike them, are free to go elsewhere.

By the same token, this mutual contract gives a doctor the right to dismiss a patient. The most obvious reasons are failing to pay or missing multiple appointments. Refusing to adhere to treatments can lead to dismissal. So can being abusive to the medical staff.

Of course, we need to exercise this option sensibly. Doctors cannot fire a patient in dire straits like severe pain, bleeding or a life-threatening situation. And of course, we cannot refuse to see patients because of their race, age, sexual orientation and so on.

When I read this article I felt disturbed. The article ends with Parikh considering whether to tell his colleague - the mother's new physician - about his experience with them. He writes:

I decided to keep quiet. After all, it could have just been me.

While it was apparent that the mother was being non-compliant and even hostile towards the concept of preventive medicine for her asthmatic son - the patient was the son, not the mother. Parikh "fired" his basis on the grounds that the mother's refusal for preventative care was dangerous to the son, but at the same time he did not make an effort to explain why preventive care is important. This is particularly striking as he claims that preventive care is embedded in his DNA.

The concept of "firing" a patient becomes even more delicate when we factor in race. The relationship between race dis-cordant physicians and patient is already rocky. Ironically, Parikh has written an article based on Burgess and van Ryn's studies on the role of race and ethnicity within physician-patient relationships. Due to factors like pressure to make a diagnosis within a short period of time, stress, and lack of cultural knowledge on the physician side, it is easy to rely on internalized stereotypes and feel frustrated by patients enough to create bad feelings. This often results in poorer health outcomes for the patients.

Even class and sexual orientation can affect the physician-patient relationship just as much as race. To avoid these rash decisions, it's important to educate physicians on how to interact with patients and create interventions to act upon in certain situations.

For those interested in supplemental reading:
- The reader comments from the NYT article are interesting
- Understanding the provider contribution to race/ethnicity disparities in pain treatment: insights from dual process models of stereotyping (Burgess, van Ryn, et al)
- Reducing racial bias among health care providers: lessons from social-cognitive psychology (Burgess, van Ryn, et al)
- Why do providers contribute to disparities and what can be done about it? (Burgess, van Ryn, et al)