The Doctor–Patient Relationship, as Defined by Language
[After five rings, a robot answers the phone number the caller was given upon leaving the hospital after surgery.]
Robot: This is Firm A. If this is an emergency, please hang up and dial 911. Otherwise, listen carefully to the following options: For billing, please press or say 1 [a long list of options follows]. If you’re calling for something else, say “something else.”
Caller: Something else.
Robot: Please stay on the line for the next available operator. Your call may be monitored for quality control and training purposes.
[A considerable pause, with music playing, along with an ad for services by Firm A.]
Recorded Voice: If this is an emergency, please hang up and call 911. Otherwise, please state the purpose of your call for me to direct your call appropriately.
Caller: It’s three days after my surgery with Dr. X. I have a problem. Dr. X asked me to call if I had a problem.
Recorded Voice: You have a problem after a surgery with us, is that correct?
Recorded Voice: I am connecting you with Triage.
[Considerable pause, with music; human voice answers.]
Triage: This is Client Triage. Before we proceed, please state your full name, address, date of birth, if you are a current Firm A client, your Firm A client number or social security number, and your insurance information.
[Caller complies with all of the above.]
Triage: Is your insurance current?
Triage: What is the nature of your call?
Caller (sounding desperate): It’s three days after my surgery with Dr. X. I am bleeding. I need to talk with Dr. X. I am also in a lot of pain. Please put me through to Dr. X.
Triage: It is Firm A policy for me to take your history first. Please describe your main symptoms for me.
Caller (close to crying:) I am bleeding!
Triage (sounding phlegmatic): From where are you bleeding? When did your bleeding start? How much blood have you lost? Why do you believe your bleeding is related to your surgery?
Caller (now crying): I am bleeding from my surgical wound. It started today. I don’t know how much I bled. Please, please, let me speak to Dr. X. He will understand. He asked me to call if I had any problem.
Triage: Our staff employee, Provider X, is not on call. I can give you a clinic appointment to see him in three months.
Caller (exasperated): I have a problem now!
Triage: I understand. I will refer you to the next available staff provider employee. The provider employee will call you when the provider employee is free; I do not know when that will be. You might wish to go to Urgent Care. If you believe this is an emergency, please hang up and dial 911. Thank you. Goodbye.
Is the above exchange a dark parable? Is it a prediction? Does it represent the present?
A lexicon or thesaurus of ambiguous, euphemistic language is probably required to understand the Orwellian (George Orwell, born Erick Arthur Blair; author of “1984,” published 1949) “Newspeak” that is engulfing our profession. The administocracy (see below) of health care has introduced many new terms into our medical vocabulary, and as Orwell fully appreciated, words are transformative precursors of reality.
An approximate trigger point for transitions in the language of health care can be dated to Michael Hammer and James Champy’s book on reengineering (“Reengineering the Corporation: Manifesto for Business Revolution,” published 1993) and its influence. The essence of the book’s message is that because knowledge is transient, it was important to reconsider it, to start over with a clean slate. In medicine, reengineering would renounce the past, the laboriously accumulated body of science-derived medical knowledge. The reengineering doctrine ran a brief course in the business world, was advocated for use by some in medical schools, and subsequently reengineered itself away.
But not fully so: Recently, the dean of a well-known medical institution asked the student body for its recommendations to decrease their feelings of burnout. Requests were made for days off for “rest and recovery” and more time for “self-care and wellness.” The third suggestion was even more remarkable: The students asked for “less volume of information in the curriculum for years 1 and 2.” In other words, their request was for aspiring physicians of the future to be burdened by less medical knowledge in the care of their future patients.
Newspeak Lexicon for Medicine
Administocracy (noun). A term introduced by Henry Buchwald in 1998 (Surgery 1998;124:595), the administration of an institution that believes itself to be in a sanctified position of top-down control, following a chain-of-command structure.
Provenance: Introduced in the latter part of the 20th century, administocracy is the ceding of authority to a cadre of those designated as leaders and senior leaders, presided over by a dominant leader. Administocracy controls opportunities, physical resources, and above all, income. It has the ability to hire and to fire, and therefore possesses ultimate power. The earners of income in a medical facility are the recipients of the residue of the earnings after the administocracy has been fully compensated, monies spent on corporate perks, as well as on executive search agencies to identify additional individuals to add to their number. To perpetuate this system, one medical school has created a special three-year curriculum to develop “physician leaders.” Benjamin Ginsberg, of the Johns Hopkins Medical School in Baltimore, has termed this system “imperialism” (“The Fall of the Faculty: The Rise of the All-Administrative University and Why It Matters,” Oxford University Press, 2011).
Firm (noun). A business organization that sells goods or services to make a profit.
Provenance: Introduced into medical Newspeak in the latter part of the 20th century to proclaim that medical care is offered in a business-like manner at a minimal cost to the firm for maximum profit. The primary goal of using this term is to instill in health care providers the concept that health care is a business conducted for profit, like any other business, and that they are the provider part of this business. This orientation dictates that the money-making human resources (formerly, the doctors) should have their time allocated for maximum utilization in tending to the needs of the firm’s clients (formerly, the patients); that equipment, supplies and drugs will be purchased from the lowest bidder; and that staffing and facilities will be streamlined without any waste of assets.
Staff (noun). A group of people that works for an organization or business.
Provenance: In medical Newspeak, the staff and specialty units within a staff, work for the firm under the authority of a management administocracy within a business model of operation. A subdivision of the staff, namely the team, practices a form of egalitarianism with a caveat. Based on Orwell’s book “Animal Farm” (published 1945), all members of the staff team are equal, but some are more equal than others. To illustrate, the members of a health care team have equal authority in making a life-and-death decision for a client (formerly, the patient), for example, in a surgical care conference involving a critically ill client. The surgeon has a vote equal to that of the intensivist, the ICU nurse(s), other unit personnel, the chaplain, and a bioethics faculty person who first saw the client that day. However, in the ordinary daily functioning of a team, decisions are usually made by providers (formerly, doctors) other than surgeons, because the surgeon’s time in the system is most useful when it is spent in the operating room making money for the team, and first and foremost, to support an ever-increasing administocracy.
Client (noun). A person using the services of a “professional person” or company. In medical Newspeak, the word means a person once called a patient using the services of a professional health care firm.
Provenance: In order to follow a business model, the “Brave New World” (a novel by Aldous Huxley, published 1932) of medicine eliminates the moral challenge of caring for the tribulations of a fellow human’s pathology of body or mind, pain, incapacitation, faith and hope, and instead substitutes the concept that a client has contracted a firm for a service for which a fee will be required. When the client accepts those conditions to obtain medical care, the client accepts seeing a provider (formerly, a doctor) at the scheduling decisions of the firm. The client relinquishes the privilege of selecting a particular provider to being serviced by a team, a team with interchangeable personnel, whose rotation is decreed by the team’s flowchart. To give two examples: A client undergoing surgery should consider the possibility of a change of surgeons during an operative procedure. Obstetrics clients should consider the possibility of a change of obstetrician during a delivery. These conditions exist today and are becoming more widespread.
Provider (noun). A supplier of services.
Provenance: In health care Newspeak, “provider” began to be substituted for doctor in the late 20th century. This alteration is consistent with the business model of health care and clearly establishes the relationship of the provider to the client (i.e., the provider is the individual in a firm who supplies a service, in this case, the service of managing a health problem). From the perspective of the health care administocracy, this definition removes the aura of the physician as a highly trained professional of independent stature. The term is a denial of physician individuality with the substitution of physician anonymity. The provider becomes any member of a service cadre.
Employee (noun). A person employed to work for wages or salary, especially at a non-executive level.
Provenance: The transition from doctor to provider was, as stated, achieved in the latter part of the 20th century; the transition from provider to employee was accomplished in the early 21st century. Except for some urban institutions and rural practices, all providers (formerly, doctors) have become employees. As employees, they receive a salary, allowances, family health care and retirement benefits from their employer institution, which relieves them of the responsibility for the time commitment and problems associated with billing and managing facilities. Further, as employees, they are assigned regular working hours, vacation time and family benefits. Their time spent with each client (formerly, patients) during a clinic visit is prescribed; on-call hours are for designated functions. They are freed from taking off-hour emergency calls from the firm’s clients. Their clients are assigned by the firm. The obligation for the subsequent care of the clients is a function of the firm. Employees are hired by a firm and of course, can be fired by the firm. If employees do not practice according to the policies of the firm, they can be severely admonished. Surgeons can be told what instruments and drugs to use; how long a client should be hospitalized; whether or not a client should be admitted to the hospital; and the appropriate uses of common appliances (e.g., Foley catheters). As stated, they may be subject to being substituted for during an operative procedure. Finally, the operative procedures that surgeons are allowed to perform are prescribed; certain practices of care for their clients may not be allowed. The former doctor has become hired help.
Within an extremely short period of time, the doctor–patient relationship of the past several centuries, dating back to the time of Hippocrates (460-370 bc), with all that this relationship meant to both parties, has been reengineered. In fact, it has been destroyed. When we were still doctors (prior to becoming providers or employees) and we referred to our patients (now clients) as “my patient,” this declaration was not a prideful boasting of ownership; rather, doctors were making a statement about assuming responsibility for another individual’s welfare. Doctors took ownership of patient care. And when a patient spoke of his or her “doctor,” the patient was expressing trust in an individual, in fact, often entrusting their very lives to the care provided by that person. The terms “my patient” and “my doctor” represented a personal relationship not consonant with a staff team of providers within a firm.
William Osler may have best expressed the relationship we have lost or are still in the process of losing in his essay, “Aequanimitas” (published 1904): “The practice of medicine is an art, not a trade; a calling, not a business; a calling in which your heart will be exercised equally with your head.”
I believe that we, as doctors, engage in a profession that performs a humane service, not simply one that delivers a commodity. This concept is the essence of who we are and what we do. In future columns, I will continue to explore the subject of the doctor–patient relationship as it pertains to different generations of practicing physicians, as well as its impact on health care.
‘Wherever the art of medicine is loved, there is also a love of Humanity.’—Hippocrates, “Aphorisms”
Dr. Buchwald is a professor of surgery and biomedical engineering, and the Owen H. & Sarah Davidson Wangensteen Chair in Experimental Surgery (emeritus), at the University of Minnesota, in Minneapolis. His articles appear every other month.