The doctor-patient relationship is well defined. Doctors are expected to be there for their patients in times of need, and most would agree on what is expected. When we think of this relationship we typically think of a one-on-one, intimate relationship built on trust and confidentiality. However, what responsibility does a physician or health care provider have to his/her community?
This question first came to mind when we were discussing antibiotic resistance in class. Physicians over prescribe antibiotics at an astounding (and alarming) rate. Because of this, we are producing good outcomes for individual patients, but are setting ourselves up for complete failure in the long run. While some argue it is because of a lack of physician education or competence, I feel it goes a little deeper than that.
Medicine is a patient-centered field. When I say that, I mean that we tend to focus on a single patient most of the time. The majority of the system is set up to reward doctors that make patients happy. Happy patients mean more referrals, more patients, fewer lawsuits, etc. Community health issues are often left to researches, public health workers, hospital administrators, etc. So what do we do if making the patient happy happens to contradict what is best for the community?
Antibiotic resistance is already a major issue; diseases that were easily treated 10-20 years ago are now resulting in severe infection and patient deaths. The problem is that many physician groups have already agreed on the best evidence-based medicine to avoid further antibiotic resistance, yet few follow these best practices. I believe the reason for this is that when you have a patient in front of you paying for your services and wanting a drug to make their illness better, it is easy to oblige them even if you are unsure this the best course of therapy. It can be difficult to tell a patient to just go home and rest.
Unfortunately, nothing in medicine is ever certain. If doctors did the “right” thing and more readily sent patient home without antibiotics if there was no conclusive evidence of significant bacterial infection, there would be more patients returning several days later (after the infection had developed further) showing the signs of bacterial infection and requiring antibiotics. I don’t know about you, but I would rather just go to a doctor once, pay one copay, take off work once, etc. Doctors don’t want patients to come back angry about these issues.
In the hospital setting, there is a temptation to reach for the more powerful antibiotics rather than messing about with first-line therapies that may or may not work. Unfortunately this is leading to resistance against our more powerful antibiotics, leading to untreatable infection. As the doctor it is much easier to prescribe the more powerful antibiotics, it is less work and there is a much greater likelihood of good outcomes for the patient over a short period of time. As a patient, I am sure you would want the more powerful antibiotic; you would want the drug that would be most sure of curing you the fastest. Acquired resistance is very real but is easy to view as something far off in the distance.
Doctors certainly care about community health, and some have been outspoken to focus our efforts towards community to achieve the greatest benefit. However, the same tangible benefits that are readily seen when focusing on a single patient’s health are not always present or obvious in the context of community health. The way our healthcare system is designed seems to only encourage focusing on single patients and not the good of the masses. The doctor-patient relationship may be will defined, but the doctor-community relationship is variable and up to interpretation.
As the debate rages on regarding the best way to improve healthcare in this country, let us not forget this issue. In order to change, doctors and patients will both have to change the way they think. The only way this will happen is if there is more incentive for both groups to change. If we become severely near-sighted and only focus on immediate outcomes for individual patients, we may be setting ourselves up for future failures.
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