Here’s a devil’s advocate position.

Historically doctors have held power over patients as compensation for the responsibility of that position, and the epatient and other patient advocacy movements seek to address that imbalance with good reason, arguing that the doctor-patient relationship should be equal.  I don’t mind that. But let’s be truly equal partners then.

The patient’s right to choose a doctor and be informed of the best ones via doctor rating sites is well established.  So what about a doctor’s right to choose his patients and screen out the bad ones beforehand?  Because, just as there are bad doctors, believe me, there are equally “bad” patients, who arrive late or skip appointments, do not follow good medical advice, malinger, abuse prescription services, do not pay for services, and are malicious litigators. Although both are heavily in the minority, the damage done can be disproportionate to their numbers and affect everybody.

Today’s environment in which doctors practise is dramatically different to that of even ten years ago.  The rise of the empowered patient, the age of easy access to information, (correct or incorrect), managed healthcare, social media platforms, and doctor rating systems have changed everything.

Although I welcome many aspects of the change I, like many other doctors, feel increasingly vulnerable, because the rules of engagement in conflict are skewed against us.  Doctors are not “allowed” by public disapproval to fight back, countersue, and respond directly to social media criticism.  We have to take it on the chin.  We are forced into being reactive to challenges and threats, not proactive in being able to guard against them.

So, for example, some doctors have tried to make patients sign gag orders limiting criticism on social media platforms.  The problem with this is that the doctor-patient relationship is formed from a default position of mistrust.

In reality, it is impossible for a doctor to have a 100% happy patient record, especially when money is involved.  In my experience, just about every patient unhappy with me has been so, sometimes long after the illness/disease/surgery has healed, about having to pay for the service.  In a small community especially it is easy to see the same patients doing the same things to other doctors as part of a recognizable recurring pattern.

I remember each and every one of those encounters in great detail because of the unpleasantness of it all, while my successes are long forgotten, and because in most cases patients angry with me have in my opinion been unfair and unrealistic.  In other words, they have been part of the spectrum that all those who deal with human beings should expect, but bad behavior in all aspects of life should not be condoned, and especially not under the banner of “patient privilege.”

I’m not perfect by any means, and I make more mistakes than I like, but I admit to them, and do everything I can to correct the wrong and fix the problem. The present situation however allows difficult or hostile patients to repeat a pattern of activity without consequences, and doctors are vulnerable, especially as unhappy patients now have the power to do great damage to reputations via Facebook, Twitter, and other media like doctor rating sites.

Doctor rating services in effect punish bad doctors by limiting their access to patients through a collective and highly public reputation.  In the interests of equality, let’s then consider a patient rating system for access by registered doctors as well, one that warns doctors against bad patients, and in the same way as doctor-rating sites “encourages” these patients to behave responsibly.  Clinical details have to be confidential, but data on the system could include patient tendencies to misbehave as detailed earlier.

Why not?  Financial, investment and insurance agencies have rating systems for their clients.  Governments have dossiers on their citizens expressly to identify those who misbehave.  Why not doctors?

Would I really welcome such an initiative?  If you ask me in the minutes after dealing with a hostile patient, my emotions will probably say yes.  But when I have calmed down, no, we can’t go down this road.  This is not what medicine is about.

But then I do not think medicine can ever really be an equal partnership, despite what patient and consumer advocacy movements call for.  If these really think it can be, then all doctors in practice and patients need to know from them by open discussion and debate why the argument in this post is a bad one.

Martin Young is an otolaryngologist in South Africa and founder and CEO of ConsentCare.

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