Patients often assume that their illness is the doctor's sole concern, and that decisions are based strictly on what is best for them. This is not always the case. Doctors' decisions are based on a host of competing interests and pressures, in addition to being directly affected by human problems such as lack of sleep or family conflicts. There are many agendas that can consciously or unconsciously affect doctors' treatment of patients.

Time and money

I get the bum's rush every time I go to my doctor. I wait forever, then I'm whisked into a cubicle, spend ten minutes getting examined, then he's gone without even making eye contact. I feel like I can't even get a word in without ruining his day. I don't like it.

Choices on how to allocate limited time and how the doctor is paid directly affect medical decision-making. Because most fee schedules pay more for tests and procedures than for taking histories, doctors who spend a lot of time with patients doing thorough examinations and learning about the patient's family, eating habits, exercise program, and stresses make less money. Writing prescriptions takes less time than discussing lifestyle changes, but it allows doctors to see more patients daily, thereby increasing incomes. Giving an electrocardiogram generates more income than listening to the heart; doing a coronary bypass is more lucrative than assessing the patient's eating and exercise habits and encouraging healthy changes; removing a wart pays more than reassuring a patient that it will do no harm.

Doctors who get paid by the procedure, especially if they have a financial interest in the equipment or facility, tend to order more tests than doctors on straight salaries. On the other end of the spectrum, HMOs often tie the doctor's salary or bonuses to how well he keeps costs down, sometimes causing inappropriate withholding of tests or procedures. Thus, there may be factors other than concern for your health that influence the medical care you get from your doctor.

One doctor sums up the reasons for taking the time to form a partnership with your doctor:

I think what's going on in medicine today is antithetical to what medicine really should be. To me, medicine is a relationship between two people, and that relationship is based on trust and understanding. It fascinates me that in double blind, controlled drug studies, about 30 percent of the people in the placebo group get better. That's a powerful phenomenon. Part of that, I am convinced, is the trust and confidence of the patient in the advice and human relationship with their doctor. What's happening in our society is that in the last twenty years doctors have bought into the idea that what they do is a commodity. Far too often, the doctor-patient relationship is reduced to this technical fix, assembly line medicine. Quite frankly, that's not medicine. Rather, medicine is a healing event that requires the participation of both people and knowledge of one another. The patient has to know and trust me. There is a need for me to reveal some of who I am to a patient--and they reveal who they are--in order for healing to take place. And that takes time.

Philosophy

Doctors differ enormously on their philosophy of practice-that assemblage of beliefs, opinions, and values that color all decisions. A woman with breast cancer could consult a surgeon, oncologist, and radiologist, and get three completely different opinions of how to treat her disease. In general, doctors tend to treat as they were taught. Hence, surgeons generally recommend operations, internists give drugs, radiologists have a bias toward X-ray treatment. Not only are there big differences between individual doctors, there are striking regional differences as well. Where you live, your gender, and the color of your skin may dictate the type of medical treatment you receive.

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Age, sex, race, and address affect medical care

The Harvard Medical School Department of Health Care Policy studied variations in the use of coronary angiography (X rays of the heart after injection of a radioactive substance) in patients who had suffered a heart attack. They found that the procedure was used most for young, white males. Blacks had less access to the procedure than did whites; women were less likely to receive the procedure than were men. The racial differences were most pronounced in the southeastern states. Also, older patients were less likely to receive the procedure. There were also wide variations among states; for instance, patients in Montana were three times more likely to have the procedure than were patients in Rhode Island.1

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Most patients mistakenly assume that treatment plans are based solely on scientific fact. Opinion, that thing that everyone has one of, determines treatment more than you might realize. In fact, the doctor's philosophy of practice colors decisions in extremely significant ways.

• Importance of prevention. Some doctors emphasize a healthy lifestyle to prevent or control illness. If you see such a physician, he might recommend changes in diet, smoking, alcohol consumption, and exercise to control your coronary artery disease. Other doctors, with a different philosophy regarding prevention, might simply refer you to a surgeon for a coronary artery bypass. Some patients are unwilling to take responsibility for their health and wish for a "magic bullet" in pills or surgery; others desire to try all preventative methods first. Try to pick a doctor whose views on preventative care match yours.

• Personal value system. You may be the type of person who needs to research your condition to feel comfortable, while others want to pick a competent doctor and rely on her wisdom. To find a good match, you'll need to discuss your values with your doctor and express clearly what you want from her.

         My primary care doctor told me something of immense value several years ago when I needed to see a specialist for an acute condition. She said, "We need to pick your doctor carefully because I know you. You are an information seeker. We need to make sure that we find someone philosophically aligned with you or you are going to clash. You know, doctors occupy a continuum of medical philosophies, and you need to find a match. There's also the question of different communication styles--we need to find a good talker. Let's make sure we find the right person." That advice has guided me for years. I put in the time now, and reap the benefits of good medical relationships later, when I really need them.

  Other kinds of mismatched values can also cause problems. If your gynecologist staunchly opposes abortion for any purpose, you might not be referred for genetic testing early in pregnancy or be given the option of amniocentesis. Conversely, if your religious beliefs forbid the use of blood products, your surgeon might refuse to operate without your consent to receive blood if necessary. A mismatch in values between doctor and patient almost guarantees conflict.

• Level of intervention. Some doctors--whose motto is "life at all costs"--aggressively treat disease until all options are exhausted. Some patients desire this no-holds-barred approach. Other doctors are more selective in their use of technological intervention and experimental drug therapies. Patients of these doctors would probably be given a range of options, with the risks and benefits of each discussed. A good match in medical aggressiveness helps to create an effective patient-physician partnership.

• Patient roles. Patients are sometimes equal partners in their medical relationships. The doctor presents all known facts, gives his opinion and explains its basis, answers the patient's questions, and respects the patient's right to make the ultimate decision. Other doctors give only partial information and restrict or redirect questions. Some doctors make all decisions for their patients and expect submissive compliance. A few doctors expect to be treated as the ultimate medical authority, revered and obeyed. In his book Doctors and Patients: What We Feel About You, Peter Berczeller, M.D., states his position:

         Our expectation is that all patients will give us immediate obedience and respect--and 100 percent of the time at that! ...besides, if we have sacrificed so much of our time and energy for the ultimate sake of our patients, should we not at least be rewarded by their keeping quiet and doing what we tell them to do? 2

  Unless you take the time to find out, you won't know whether your doctor's philosophy is autocratic or democratic.

Curiosity

Doctors are often intellectually curious, especially when dealing with rare or perplexing illnesses or when training medical students. In these cases, tests and procedures are often performed to find out more about a disease than to influence treatment. In some settings, a patient may be treated as simply a body; his illness may be viewed as a puzzle to solve rather than something that is impacting his life. Doctors and medical students sometimes forget that tests are expensive and often cause side effects. Moreover, adults need to miss work, plan time to recuperate, make child care arrangements, and endure whatever tests are given. Often these issues are not discussed or even considered prior to orders being written. Sherwin B. Nuland, M.D., in his book How We Die, labels this curiosity:

       The quest of every doctor in approaching serious illness is to make the diagnosis and design and carry out the specific cure. This quest, I call The Riddle, and I capitalize it so there will be no mistaking its dominance over every other consideration. The satisfaction of solving The Riddle is its own reward, and the fuel that drives the clinical engines of medicine's most highly trained specialists. It is every doctor's measure of his own abilities; it is the most important ingredient in his professional self-image...Every medical specialist must admit that he has at times convinced patients to undergo diagnostic or therapeutic measures at a point in illness so far beyond reason that The Riddle might better have remained unsolved.3

Boredom

Some doctors are bored. After the excitement of training in large medical centers where many rare and complicated cases are thoroughly studied and discussed, opening a practice can be a letdown. Doctors who provide primary care spend day after day explaining why antibiotics won't work for viral infections or how to prevent constipation in children. For a newly pregnant young woman, each visit to the doctor is a chance to discuss every aspect of the exciting pregnancy, but for the obstetrician it may be just another time to recite the litany that he has recited thousands of times before. Many patients notice a difference in treatment when they develop a challenging illness or a rare abnormality.

       I had an OB/GYN who I thought just had a lousy bedside manner (and only later found out he had a drinking problem). He was pretty darn bored during my first pregnancy. Then I had an inverted uterus during delivery (a one-in-a-million complication in women, although rather more common in dairy cows). He became very interested in me then, as were all his colleagues; I had become an interesting case. All during my next pregnancy, he was also very attentive. I couldn't shake the feeling that he was hoping that I'd have an inverted uterus again, and become an even more rare statistical anomaly.

Teaching

The interests of doctors and patients may sharply diverge when trainee doctors are involved. Many sick patients at training hospitals are familiar with the discomfort associated with having five pairs of hands palpate a tender abdomen or having a student struggle to draw blood from a small vein. In Patient Beware, Cynthia Carver, M.D., describes an experience that happened to her in a maternity clinic prior to her entry to medical school:

       Off went my clothes, and on went the little white gown. The nurse helped me up onto the examining table and put my feet in stirrups...and draped a sheet over me. The sheet prevented me from seeing anyone seated between my legs, but left my genitals exposed to the world at large...

       After ten minutes or so the doctor came in, and to my relief he was middle-aged, friendly and non-threatening. He examined me gently but thoroughly, and as he finished told me that everything was fine.

       I started to withdraw my feet from the stirrups, but the doctor stopped me, saying, "Just stay there for a minute. I'd like another doctor to check you." ... Suddenly there were four young men standing there, all gazing at my bottom as he pointed out the details of my anatomy. He then relinquished his place between my legs to one of the young men and instructed him to repeat the pelvic exam. I was horrified. I started to cry. 4

Many people do not realize that training of student doctors extends into the operating room, where senior physicians supervise residents as they learn their trade. All students have to practice to become competent, but you can be in charge of when, where, and how by scrutinizing consent forms and discussing all aspects of your care with your primary doctor.

        When my husband needed delicate surgery on the nerves in his arm, we traveled over a hundred miles to go to a surgeon with an excellent reputation for hand and arm surgery who operated at a large teaching hospital. When we went in for the pre-op visit, we were seen by two residents, one of whom handed us a two-sided piece of paper covered with small print. Buried on the second side was the section in which patients gave permission for the surgeon "and his colleagues" to perform the surgery. When we told the two young residents that we had traveled a great distance to have Dr. D. perform the surgery, one became quite frosty and told us huffily that he had "two and one-half years experience" and his senior resident had "six years experience." When you are in your seventies and some fresh-faced youngster crows about his two and one-half years of experience, it's not too impressive. He was obviously offended that we would question his credentials, or worse, refuse to let him perform this surgery. Nevertheless, we scratched out "and his colleagues" and had Dr. D. do the surgery.

When you are treated in a teaching hospital, most of the orders for your care are written by doctors-in-training--residents or interns--who are fearful of missing anything that their instructors might point out. Young doctors routinely work more than 100 hours each week, are required to memorize huge volumes of information, and sometimes experience a boot camp mentality in which humiliation and contempt prevail. This training frequently results in exhausted, fearful young men and women who are afraid of making mistakes and do everything in their power to cover all possibilities. Of course, these multiple tests and procedures protect the student from the wrath of his instructor, but may not be in your best interest.

Politics

Political problems of all stripes can affect the treatment a patient receives from a doctor. HMOs sometimes restrict a physician's ability to refer patients for specialized care or may restrict referrals to a specialist within the same plan--who may not be the best person for the job. Hospitals may discourage or even forbid referrals to physicians not on staff.

Office politics sometimes affects patient care. For instance, doctors who are extremely competitive may feel uneasy asking a colleague for an opinion, even if they are unsure of a diagnosis or best treatment. Residents may order unnecessary tests in order to impress their instructor. A physician who also is a researcher may encourage, sometimes even pressure, patients to enroll in a clinical trial to further his own professional goals rather than presenting options and allowing patient choice. For-profit hospitals sometimes put making money above providing good patient care. Political pressures such as these may consciously or unconsciously drive doctors' decision-making.

In M.D.: Doctors Talk About Themselves, one physician describes the rapidity of changes wrought by politics at his hospital:

       The children's hospital where I work used to be run by doctors; now it's run by businessmen. We used to advertise our excellence by publishing in journals, by teaching, and by presenting our studies in medical meetings. Now we do marketing. At the same time that the hospital is telling us we've got to make money to keep our departments going, we're told we have to publish or perish to keep our academic appointments. I'm at a point where I can't staff my department as I should. And all of this has happened in the last five years. The speed has been unbelievable

       We used to work for patients. It was our responsibility to do as well by them as we could. We were their advocates. No doubt we'd sometimes screw up or order too many tests, and some of us were probably lousy doctors, but the bottom line was that we were working for them. Now we're working for the company that owns the hospital.5

Defensive medicine

Doctors do not want to be sued. To lower their risk of getting sued, doctors often order unnecessary tests and prescribe unnecessary drugs. They want to be able to show that they did everything possible, they covered all the bases. Studies show, however, that this type of defensive medicine does not lower the risk of getting sued. What most determines whether a doctor is sued is whether the patient likes the doctor and feels cared for.

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Physicians' perceptions on the risk of being sued

A group of scientists at Harvard University studied physicians' perceptions on the risk of being sued and how this perception affected their practice. They found that physicians in the study estimated that 19.5 out of 100 of their colleagues would be sued in a given year, approximately three times the actual risk. In addition, the doctors estimated that 60 percent of problems caused by negligence would result in a suit, which is 30 times higher than the actual risk. Fewer than 2 percent of the patients in New York injured by negligence actually filed malpractice claims. Physicians responded to their fear of malpractice suits by increasing their use of tests and procedures, spending more time discussing the risks of medical care, spending more time on paperwork (e.g., the patient's chart), and reducing the scope of practice.6

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Unfortunately, defensive medicine has thrown out the concept of "watchful waiting." In the past, doctor and patient would agree to keep an eye on the condition, which would often resolve with time. Not anymore. Now, defensive medicine inflates the cost of medical care and subjects patients to the risks, discomforts, and expense of unnecessary tests and drugs.

Impaired doctors

Impaired doctors are nothing new. However, the stresses of being a doctor are bad and getting worse. The rise of HMOs is dramatically changing health care delivery and making some physicians extremely uncomfortable. Many third-party payers are second-guessing physicians' judgments and often refusing to pay for prescribed treatment. Paperwork requirements increase constantly. Patients are more educated and far more demanding than in the past. In addition to these stresses, doctors with addictive tendencies may be sorely tempted by the availability of drugs at their hospitals.

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Doctors who use alcohol and drugs

Thousands of U.S. physicians were sent questionnaires to elicit information on the use of various substances. The authors found that doctors were less likely than the general population to use cigarettes, marijuana, and heroin, but were five times as likely to take sedatives and minor tranquilizers without medical supervision. They note that these estimates are based on self-reporting and do not control for the tendency of people to deny a substance abuse problem. Other studies are cited which estimate the rate of alcohol abuse by physicians to be between 13 and 14 percent.7

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Most state medical societies have recognized the problem of drug usage by doctors and have responded by implementing special treatment programs for impaired physicians. A recent editorial in the Journal of the American Medical Association recommends:

       All [medical] societies should follow the lead of the 25-plus states that now prohibit physicians from prescribing controlled substances for themselves or for their immediate families. Second, the physicians of physicians should be encouraged to seek urine tests for opiates and blood tests for sedatives in any physician patient who presents as a diagnostic enigma. Third, hospitals should have procedures in place to refer addicted physicians for appropriate treatment, including well-supervised and long-term random screening of their urine for drugs. Fourth, I propose that some medical staffs establish trial programs of random urine screening tests for all of their members.8

Notes:

1.   C. A. Gatsonis et al., "Variations in the Utilization of Coronary Angiography for Elderly Patients with an Acute Myocardial Infarction," Medical Care 33, no. 6 (June 1995): 625-642.

2.   Peter Berczeller, M.D., Doctors and Patients: What We Feel About You (New York: Macmillan, 1994), 17.

3.   Sherwin B. Nuland, M.D., How We Die: Reflections on Life's Final Chapter (New York: Alfred A. Knopf, 1994), 248.

4.   Cynthia Carver, M.D., Patient Beware: Dealing with Doctors and Other Medical Dilemmas (Scarborough, Ontario: Prentice Hall Canada, Inc., 1984), 8.

5.   John Pekkanen, M.D.: Doctors Talk About Themselves (New York: Delacourt, 1988), 55.

6.   A. G. Lawthers et al., "Physicians' Perception of the Risk of Being Sued," Journal of Health, Politics, Policy and Law 17, no. 3 (Fall 1992): 463-82.

7.   P. H. Hughes et al., "Prevalence of Substance Abuse Among U.S. Physicians," Journal of the American Medical Association 267, no. 17 (6 May 1992): 2333-9.