The doctor-patient relationship has changed over the past 20 years. What used to be a paternalistic relationship, where the doctor had access to all of the information and made all of the decisions, has become much more of a give and take. Patients have access to an infinite amount of information about health via the Internet (some good, some not so much), and want to be active partners in their health care. The doctor still has years of training and experience to rely on, and that makes him or her a trusted adviser, but decisions are shared much more than they were in the past. This is a good thing. Not only does it allow people to do what is consistent with their values and goals, empowered patients are more likely to take action to make lifestyle changes to improve their health, as opposed to having the doctor prescribe a pill to take care of it — often less effectively.
These days, we hear a lot about limited health-care resources. Canada spends about 11 per cent of its GDP on health care, or about $6,100 per person annually. This is higher than most countries, although significantly less than the United States.
But the key to better health care is not just spending a lot of money, but spending on the right things. Millions of dollars are wasted every year on useless and even harmful testing and treatments.
Working together, doctors and patients can help society spend more on tests and treatments that are proven to be effective, and less on useless and harmful ones. There are a number of examples of how this can work.
Screening tests check for evidence of disease in asymptomatic patients. The idea is great — find cancer or other diseases as early as possible, before there are symptoms, to maximize the chance of control or cure. But screening tests are not all totally benign: While I personally know people who have had cancers discovered early and cured thanks to a screening colonoscopy, I also know of people who have had serious outcomes, even death, as a result of complications from a screening colonoscopy.
In 2014, Canada joined the Choose Wisely campaign to encourage doctors to speak with their patients about what tests, treatments, and procedures are actually proven to be of benefit to someone in their circumstances. Examples of recommendations are: not to do imaging for lower back pain unless there are red flags; not to use antibiotics for viral respiratory tract infections like a cold, or flu; not to do screening EKGs and chest X-rays; not to do Pap tests in women under 21 years old or over 69.
Screening EKGs and chest X-rays may find things that look abnormal, but are actually not. However, they will necessitate the patient undergoing further testing, which may be invasive and have potential complications.
Treating people with antibiotics they don’t need gives them no therapeutic benefit whatsoever (aside from the powerful placebo effect), but exposes them to the side effects of the antibiotic and contributes to the growing problem of antibiotic resistance (bugs that are not killed by antibiotics). With respect to medications, we know that many people are on medications that are not helping them and may be harming them. Thousands of Canadians are hospitalized every year because of side-effects of their medications. In stopping to prescribe unneeded medications, doctors can reduce harm significantly.
The reason why the new doctor-patient relationship is important is that the best health care is personalized. Decisions need to be made based not only on the evidence across a population, but also on each patient’s own personal risk and value system. Only by sitting down and discussing the pros and cons of tests and treatments can the doctor and patient decide what the best choices are for that person.
These discussions are the cornerstone of the new relationship between doctors and patients, and how this new relationship is improving health and directing resources toward high-yield tests and treatments.