Nurturing the Physician-Patient Relationship

Editor’s note: The Final Cut is a recurring editorial series written by a member of the AAOS Now Editorial Board.

Trust is at the heart of every physician-patient relationship. Each patient depends on more than just the presence of diplomas and certificates hanging on the wall. Rather, patients depend on the idea that each doctor will make the patient’s well-being paramount. Decisions that are ethical and based on the patient’s best interest are fundamental. A range of outside factors pull at all physicians, including productivity, financial conflicts, and insurance company demands, but being an advocate for patients should always be the highest priority.

Several factors in recent years have contributed to the erosion of the physician-patient relationship:

• Time constraints: Physicians feel pressure to see more patients in less time due to financial pressures and administrative burdens. There is increasing focus on efficiency and productivity and use of physician extenders, which can interfere with effective physician-patient relationships.
• Electronic health records (EHRs): EHRs can be a barrier to interpersonal communication. Physicians may have more difficulty identifying important data amid the proliferation of information in the EHR. Furthermore, physicians spend more time looking at screens than at their patients.
• Fragmentation of care: In many systems, patients see a range of specialists depending on their medical conditions. This can make it difficult for one physician to view the comprehensive medical picture and understand the patient’s individual circumstances.
• Communication challenges: Loss of the personal touch in electronic communication, such as with telemedicine, can make it difficult for the patient to convey the full range of their concerns. Also, some patients may find electronic communication technologically challenging. A University of Chicago study identified common reasons patients did not trust their doctors, including that the doctor did not know the patient, did not spend enough time with the patient, and did not listen to the patient. Additionally, patients complained that doctors appeared financially conflicted and did not make eye contact with them.
• COVID-19: The rapid onset of the COVID-19 pandemic has had a negative impact on the physician-patient relationship, and many consultations have become remote rather than in person, removing the personal touch of interpersonal communication. Additionally, related treatment has created confusion and conflicting advice. This confusion can lead to a lack of clarity in directing care that can pervade other non-COVID aspects of healthcare.

The increasing mistrust in medicine has many causes. The system is needlessly complex. Medical care can be tumultuous and politically challenged. There is unequal access to healthcare for minorities. Cultural and religious beliefs and historical biases can impact the physician-patient relationship. Increasing commercialism, corporations taking over medicine, and financial conflicts that affect physicians also contribute to mistrust of the healthcare system.

Among the range of issues that can interfere with the physician-patient relationship, medical conflict of interest can be subtle and unseen by the patient. The hidden effects of financial conflicts can negatively impact the physician-patient relationship. Any external influence that may impact decision making, including the physician’s choice of medication, surgery center, or type of implant can taint medical decision making. These decisions should be made free of outside or unseen interests. Although the harm to the patient may be subtle, it is still real. Medical conflict of interest can also extend to research, education, and advocacy. Patients can see how much doctors have received from outside sources on the OpenPayments database.

Financial conflicts of interest are harmful because they risk having the patient’s best interests subrogated by a secondary interest and may impact the integrity of medical judgment. All potential conflicts must be transparent to limit their impact on the physician-patient relationship.

Trust between doctors and patients is fragile and requires frequent nurturing. Even the smallest perception that any outside interest takes precedent above the patient’s interests can undermine this trust and impact the entirety of medicine. As orthopaedic surgeons, what can we do to help restore confidence in our profession? The good news is that we mostly have the confidence of the public. However, we need to be seen as leaders in improving the physician-patient level of trust. We should make sure our patients are heard and that we explain orthopaedic problems and treatments in detail. There should be healthcare professionals who look like the communities they serve. Communication should be in the language of our patients.

Orthopaedic patients need doctors who make them feel comfortable and who are not judgmental. We should always provide adequate opportunities to ask questions about orthopaedic treatments. Shared decision making between doctors and patients is crucial to navigate the financial aspects of healthcare effectively.

We can improve transparency by making sure that any financial conflicts are disclosed. This can include being transparent about healthcare costs and ensuring that medical recommendations are based on clinical need rather than financial gain. The AAOS Standards of Professionalism require revealing financial conflicts that can affect care to our patients and colleagues. This includes explaining interests in orthopaedic implants, surgery centers, and imaging centers.

Restoring trust in medicine involves several key strategies:

• Transparency: Orthopaedic surgeons should be fully transparent in their operations, such as disclosing conflicts of interest and communicating clearly about risks and benefits of treatments.
• Accountability: Be accountable to your patients and explain problems and procedures clearly. Educate them about how their treatments work and options that exist for treatment.
• Communication: Improving communication between physicians and patients is essential. Better communication includes listening to patient concerns and explaining treatment options.
• Ethical standards: Upholding ethical standards within our profession is vital. Upholding standards involves promoting integrity, honesty, and respect for patients’ autonomy and privacy. Disclose any potential financial conflicts.
• Evidence-based practice: Emphasizing evidence-based medicine helps build confidence by demonstrating that medical decisions are grounded in rigorous research and clinical experience.
• Patient advocacy: Be an advocate for your patients. Help them navigate the complexities of the U.S. healthcare system.

By implementing these strategies, we can work toward restoring and maintaining trust in medicine, ultimately benefiting both patients and physicians alike.

Thomas Fleeter, MD, MBA, FAAOS, is in private practice in Reston, Virginia, with Town Center Orthopaedics. He is a member of the AAOS Now Editorial Board and chair of the AAOS Committee on Professionalism.