We often sign extensive contracts when entering long-term commitments — think of the fine print in a mortgage, a car loan, or a new job offer.
While there are privacy forms and acknowledgments of office policies, the expectations of the physician-patient relationship are often assumed rather than explicitly stated. Some providers do outline expectations, and in today’s medicolegal environment, HIPAA notices are always signed — but that’s not the same as a mutual understanding.
I believe that a lot of misunderstandings between patients and providers stem from unmet expectations. The expectations of the doctor-patient relationship are rarely delineated in a thoughtful or methodical way. And I think that leads to tension at times.
We clearly have expectations of primary care providers — and of physicians in general. In fact, those expectations are often encoded in the laws and often with the following phraseology:
“Practice of medicine”: Means the diagnosis, the treatment or the correction of or the attempt or the claim to be able to diagnose, treat or correct any and all human diseases, injuries, ailments, infirmities or deformities, physical or mental, real or imaginary, by any means, methods, devices or instrumentalities, except as the same may be among the acts or persons not affected by this chapter.” (Arizona Revised Statutes Title 32:22a)
The law goes on to describe the requirements for licensure, guidelines for ethical conduct, indications for investigation by the board of medicine, and indications for discipline or censure by the state board of medicine. The regulations are extensive, consisting of exhaustive lists of what may be considered physician misconduct in the view of society or the law.
My purpose in writing this is not to delineate all those things.
My purpose in writing this is to ask this question: In the de facto contract, whether unwritten or unspoken, that is the relationship between physician and patient, do patients have responsibilities?
I propose that the answer is yes, patients do have responsibilities. In fact, the American Medical Association has published a list of patient responsibilities in their code of ethics:
Successful medical care requires ongoing collaboration between patients and physicians. Their partnership requires both individuals to take an active role in the healing process.
Autonomous, competent patients control the decisions that direct their health care. With that exercise of self-governance and choice comes a number of responsibilities. Patients contribute to the collaborative effort when they:
Are truthful and forthcoming with their physicians and strive to express their concerns clearly. Physicians likewise should encourage patients to raise questions or concerns.
Provide as complete a medical history as they can, including providing information about past illnesses, medications, hospitalizations, family history of illness, and other matters relating to present health.
Cooperate with agreed-on treatment plans. Since adhering to treatment is often essential to public and individual safety, patients should disclose whether they have or have not followed the agreed-on plan and indicate when they would like to reconsider the plan.
Accept care from medical students, residents, and other trainees under appropriate supervision. Participation in medical education is to the mutual benefit of patients and the health care system; nonetheless, patients’ (or surrogates’) refusal of care by a trainee should be respected in keeping with ethics guidance.
Meet their financial responsibilities with regard to medical care or discuss financial hardships with their physicians. Patients should be aware of costs associated with using a limited resource like health care and try to use medical resources judiciously.
Recognize that a healthy lifestyle can often prevent or mitigate illness and take responsibility to follow preventive measures and adopt health-enhancing behaviors.
Be aware of and refrain from behavior that unreasonably places the health of others at risk. They should ask about what they can do to prevent transmission of infectious disease.
Refrain from being disruptive in the clinical setting.
Not knowingly initiate or participate in medical fraud.
Report illegal or unethical behavior by physicians or other health care professionals to the appropriate medical societies, licensing boards, or law enforcement authorities.
In short, while physicians carry significant responsibility under law and ethics, patients also play a vital role in the success of the therapeutic relationship — one that is collaborative, not one-sided.
Matthew G. Checketts is an internal medicine physician.
