Subscribe to The Podcast by KevinMD. Watch on YouTube. Catch up on old episodes!

Urologist William Lynes discusses his article, “The decline of the doctor-patient relationship.” William explains why he believes this relationship, the critical center of medical care, is broken after 40 years of insidious deterioration. He argues that physicians (including himself) gradually relinquished control of clinical decisions, allowing non-clinicians, committees, and government agencies to take over. William discusses how this loss of physician autonomy and the rise of medical bureaucracy have led to delayed, inefficient, and frustrating patient care. This is a call for physicians to “claw back” control of the health care system. Learn why restoring this relationship is the only hope for the future of American medicine.

Our presenting sponsor is Microsoft Dragon Copilot.

Microsoft Dragon Copilot, your AI assistant for clinical workflow, is transforming how clinicians work. Now you can streamline and customize documentation, surface information right at the point of care, and automate tasks with just a click.

Part of Microsoft Cloud for Healthcare, Dragon Copilot offers an extensible AI workspace and a single, integrated platform to help unlock new levels of efficiency. Plus, it’s backed by a proven track record and decades of clinical expertise, and it’s built on a foundation of trust.

It’s time to ease your administrative burdens and stay focused on what matters most with Dragon Copilot, your AI assistant for clinical workflow.

VISIT SPONSOR → https://aka.ms/kevinmd

SUBSCRIBE TO THE PODCAST → https://www.kevinmd.com/podcast

RECOMMENDED BY KEVINMD → https://www.kevinmd.com/recommended

Transcript

Kevin Pho: Hi. Welcome to the show. Subscribe at KevinMD.com/podcast. Today, we welcome back William Lynes. He is a urologist, and today’s KevinMD article is “The decline of the doctor-patient relationship.” William, welcome back to the show.

William Lynes: Hey, thank you, Kevin. Thank you for inviting me back.

Kevin Pho: All right. Tell us what your latest article is about.

William Lynes: Well, I began my medical practice in 1987, and I retired in 2003. I have been sort of at the sideline with my own health care, but I have been involved in advocacy for physician burnout and physician suicide. I have a lot of colleagues, and I have just been concerned about the status of health care in the United States.

I think that we see a system that is very bureaucratic and overburdened. It is influenced by government, by big business, and a lot of other things. But in asking the question of what really is wrong, I come up with really one conclusion. I think that American medicine is the jewel of world health care.

I think that you can say that it is based upon a very sensible, simple principle, which is that the patient and the doctor make clinical decisions. I use a sort of example of being in the exam room. Of course, it is not always done that way, but basically, that is the basis of it. What I see is that the relationship between the patient and the doctor has been deteriorating.

When did that start? Well, it started when I was finishing my practice. I did not know about it at the time. But as I look back (again, I retired in 2003), there were some things already that influenced my ability to make clinical decisions. For example, I think it was around the late 1990s or early 2000s that I first became aware of what a physician assistant was. We had a physician assistant, and he offered to do history and physical exams prior to my surgeries. I thought at the time that was a very efficient thing to do, and I allowed him to do it.

But in retrospect, I am not sure it was the best thing because the history and physical before surgery, at least in my surgical practice, was a very important time for interacting with the patient where I reviewed, really for the first time, their entire medical history and surgical history. I always included with that at the end a very detailed description of what the risks and complications of the surgery were and what the surgery involved. What taking that away from me did was remove that big chunk of time that I spent with the patient.

Now, I was still able to do informed consent, talk about surgeries, etc., but it was not in the exam room. It was over the phone, or it was during the pre-op time just before surgery. Really, it was different.

There were other things on the horizon at that time. Again, I did not appreciate them, such as physician-led committees which were making decisions about drugs that you could or could not use. I thought at the time that they knew a little bit more than me. But in retrospect, I think that that also was a mistake.

Now, if we fast forward to what it is now, I see that the clinician makes very few of those medical decisions. I see things like requirements about drugs that you can prescribe. I see things in which pharmacists make decisions about when and how medicines are prescribed. I see committees which decide whether or not a patient can have physical therapy and on and on.

The question is: Who is making those decisions? As I mentioned, I think that it is bureaucratic situations. So, I think that we are in a bad situation with health care in America. I wish I had hope for it, but I do not know. Time will tell.

Kevin Pho: Going back to that example where you said that physician assistant would do the pre-procedure history and physical: Did you have a choice in that? Was that imposed on you? If you insisted on doing the pre-procedure history and physical yourself, would you have been able to do that?

William Lynes: Well, at the time, yes. Completely. Again, this would be, let’s say, the year 2000. It was between me and the physician assistant at that point. I do not think it is anymore. Now it is sort of like you schedule surgery, and you are booked with a physician assistant. The next time you see them is before the surgery. I think that is the way it goes.

Kevin Pho: So you are saying that under the guise of convenience, physicians themselves have ceded some autonomy and control, and that in effect has harmed some of that doctor-patient relationship?

William Lynes: Well, yes, I think so. We have ceded a lot of it. Again, it was efficiency. It was because, to some extent, I was overburdened. It sounded good at the time, but I think most of the time that we cede the clinical decisions in regards to our patients, it is not a good decision.

Kevin Pho: So what is the answer here? Because a lot of physicians say that we are burned out with a lot of these bureaucratic requirements, but when we outsource that, by definition, we also outsource some of that autonomy as well. So, is there a middle ground here?

William Lynes: I think there is a middle ground. I think it is going to be very difficult. I think the only solution is that practicing physicians need to stand up and say: “No, that is not the way it should be done.”

The problem is the people who are making those decisions now are very powerful. There are people in organizations who think that they make better clinical decisions than the physician. I think there is some resentment in there. I think some of these people do not think that physicians make those decisions well.

Every step of the way when we are faced with having that autonomy taken away from us, we need to say no, we should not do that. Like I said, the people who are opposing are very powerful. They have money, they have government, and they have bureaucracy behind them. I think at the root of it is that they believe that they make those clinical decisions better than a physician does.

Kevin Pho: In fact, you wrote in an article that you think that many of these decision-makers have contempt for the physician. Have you actually seen that in person, or can you give an example of what that may look like?

William Lynes: For example, Mayor Giuliani recently was in an auto accident. If you recall, he got off the freeway to help someone, and he was hit and was in the hospital. Now, his medical spokesperson was a physician assistant, and she released statements to the media about him. At the end of her article, she says: “This is so-and-so, physician assistant. I am a physician, but I do not operate.” I thought that was an amazing revelation. Now, I am not saying that they all feel that way. I just think that there is some resentment. I think it is part of the problem.

Kevin Pho: You call for physicians to claw back control. When you instruct physicians to say no to something, what do you instruct them to say no against specifically?

William Lynes: I think you have to take it as an individual decision. For example, I have shoulder problems, and my primary physician and I agreed that I should have physical therapy. It literally took two committees to decide that I could have that.

Now, what would my primary physician do? I really do not know. It is sort of overwhelming. I think that he needed to stand up and say: “No. That is an obvious thing that he needs.” But I am not sure that he is in a position to do that. Maybe private practice physicians are. Maybe people who are in power, administrative physicians, are the clinicians. I am not really sure. It is a difficult problem.

I would just mention that I have not been practicing for over 20 years now. So, I sort of am looking at this from the outside, and it is pretty easy for me to make statements about these things. The reality of it is that I am not really sure.

Kevin Pho: With all this loss of physician autonomy, the crux of your article is that this is affecting what is happening in the exam room, specifically that sacred relationship with doctors and patients. Speaking from a patient perspective, tell us how some of this autonomy that is being taken away specifically affects the doctor’s relationships with patients.

William Lynes: I will tell you one big example. It is the overreach of the DEA and other government agencies regarding controlled substances. We have a problem with substance abuse in this country. There is no question about it. One aspect of the problem is that it has been facilitated by the medical community, but not all of it.

I, for example, take a controlled substance every day, and I have been taking it for 30 years. What I have seen over the last few years is this: First of all, the physician cannot write more than a 30-day supply. Second of all, they cannot write for refills. They have to be evaluated every time. Thirdly, the pharmacy started not allowing you to get your medication far enough ahead of time that you could get them through the mail. So I started getting it in the pharmacy.

Very soon, I would go to the pharmacy, and they would say: “No, you are a day early.” Or at one time, I was 12 hours early, and I could not pick up my prescription. So, that is just a sort of unbelievable overreach. Really, that goes back to the physician-patient relationship because the way it used to work is that Dr. Smith would write a prescription for a 90-day supply or just a 30-day supply of a sedative hypnotic. They would take it to the pharmacy, no questions, and it would be filled.

Now, my point is that there are problems with the original way that that worked. There were more prescriptions written. I did it myself. But there has been a tremendous overreach in trying to fix the problem of substance abuse in the country.

Kevin Pho: Do you think that the situation is too far gone? Is there any hope to reclaiming some of our autonomy back?

William Lynes: Yes. Well, I hope so because I think that, first of all, we have major problems in health care in the United States. It is too expensive. We pay much more per patient than other developed countries, and our clinical results are much less than other developed countries. So, I think for once maybe we look to other models in the world.

I tend to be a person who looks at the glass half empty. I am sort of a negative person, so I hope that it can be done. But the only way it is going to be done is for the physician to stand up and say: “No, this is wrong. We need to have physicians making these clinical decisions.”

Kevin Pho: We are talking to William Lynes. He is a urologist. Today’s KevinMD article is “The decline of the doctor-patient relationship.” William, let’s end with some take-home messages that you want to leave with the KevinMD audience.

William Lynes: I think we leave with a little hope. I believe that American medicine is a jewel. It is the model of which health care in the world has been modeled after. The relationship between the patient and the doctor is the basis of that. We have a tremendous ability to give out health care. So, I think that there is some hope, but I think that we are in a situation that is quite dire at this time.

Kevin Pho: William, thank you so much for sharing your perspective and insight. Thanks again for coming back to the show.

William Lynes: Thank you, Kevin. Talk to you later.