Something is wrong with our health care system. Our country spends more per capita than any other developed nation, yet we have some of the worst health care outcomes. Rising costs are making health care prohibitive. Access to the system is becoming a growing concern. Medical care has become bureaucratic, bulky, and inefficient. I am a retired physician, a urologist, who has observed the health care system from outside medical practice since my retirement 23 years ago. I have gained insight into medical care through my family’s experiences. There were obvious and increasing numbers of inexplicable, delayed, and frustrating events. In addition to observing medical care through my own experiences, I have interfaced with practicing physicians through my advocacy for physician burnout and suicide. I recently interviewed several practicing physicians to prepare for this position paper on the state of health care in the United States. Many of my comments are based on the results.
The most adverse factor affecting health care today is the deterioration of the doctor-patient relationship. This relationship is the critical central point of medical care in our country. The patient and physician, often in the exam room, should make clinical decisions together. Therapeutic alternatives, along with the robust discussion of risks and benefits, allow the most informed decisions to be made. This may be time-consuming, and some may find it old-fashioned, but it is of critical importance. I believe that the doctor-patient relationship in our country is nearly dead.
The deterioration of the doctor-patient relationship began gradually and progressed insidiously. The onset is debatable, perhaps dating back 30 or 40 years. In my urologic practice in 2000, the patient and I made nearly all health care decisions. In 2025, others will make the same decisions regardless of physician input. My first recollection of an obstruction to this relationship occurred during my practicing years, in the early 2000s. A physician assistant offered to do the presurgical history and physical. That was helpful without compromising patient care. In retrospect, this practice hindered my understanding of the patient’s medical history. In addition, after performing this history and physical examination, it was my practice to obtain informed consent at that time. This consent was then moved to the phone or preoperative room. It was not the same. A second early example of interference with the relationship involved drug guidelines. Sometimes, I often compromised, selecting the guideline drug despite my preferences.
The deterioration of the all-important doctor-patient relationship began in the distant past and evolved gradually. I blame the entire physician community, including myself. We relinquished clinical decision-making, seeing these as facilitating our practice. Often, this made our lives easier. In retrospect, it cancelled physician control. Non-clinicians, physicians on committees, government agencies, and large businesses made day-to-day clinical decisions.
Restoring the doctor-patient relationship will require a concerted effort. Whenever an obstruction to this relationship occurs, physicians need to take back their position as the clinical decision maker. Reversing those changes will be difficult. They will have to claw back the control. Those who are making the decisions are reluctant to give back their power. Those making choices believe that their decision-making is superior to that of the physician. Many have contempt for the physician. Many feel that they deserve to be physicians, despite their lack of training. I wish I felt more encouraged about the future of American medicine. Our profession must improve. The only hope is to reestablish the patient-doctor relationship with determination and reclaim our precious health care system.
William Lynes is a urologist and author of A Surgeon’s Knot.
