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The Evolution of the Physician-Patient Relationship:  Implications in the Treatment of Fibromyalgia and Chronic Fatigue Syndrome
by Thomas W. Shinder, MD

The Traditional American Medical model as we know it today became extant in the second decade of the 20th century. Prior to what was called the "Flexner" report, the standards in the practice of medicine were quite variable.  There were hundreds of institutions and "small businesses" purporting themselves to be medical schools, and there was little regulation regarding the quality of the education or the quality of the graduates of these schools.

After the findings of the Flexner report became clear to Congress, strict regulations and guidelines were put to fore in order to create an environment where the United States would have the best Healthcare system in the world. The goal was to limit the number of medical schools, have those remaining medical schools meet high standards of care and education, and limit entrance to the schools only to what were considered to be the "best and the brightest".

In this light began the culture of the "American Medical Model". It was also at that time that science was able to break through many of the mysteries of human physiology. Diseases such as diabetes, pneumonia, syphilis and hypertension, which killed untold thousands of people yearly worldwide, began to let loose of their secrets. And with this new knowledge, those thousands of lives were saved each year.

The "new" American Physician was a Scientist. To separate himself from his predecessors he eschewed anything which was not "objective" and quantifiable. It was because of the then new scientific approach that physicians were able to save many lives, and improve the quality of many more. The "old style" physicians depended on qualities of intuition, folklore, powers of suggestion and belief. The old ways were to be purged, so that the quality of human existence could improve unimpeded.

Inherent in this belief of scientific absolutism was the attitude that the patient knew little or nothing of the evolving scientific discoveries in medicine, physiology, chemistry and biophysics. Physicians then developed a "paternal" approach to their patients in order to help them use the new tools of scientific medicine. This paternalism certainly was not new as a medical approach, but it did become solidified as de rigueur because it would be unrealistic to expect a general patient population with marginal education to have any understanding of the diagnostic and treatment modalities which were undertaken.

This paternalistic physician-patient relationship became the standard, and was generally well received for almost seven decades. Although many a patient would be frustrated by the usually arrogant, almost always male physician, the sense of being "cared for" overarched those feelings. People trusted their physicians because it was felt the physician was beholden to only the scientific method and the fruits of that method. We trusted our lives to these physicians and their beliefs without question.

How did a person with a disease such as Fibromyalgia or Chronic Fatigue Syndrome fit into this model? What was the physician’s attitude toward these patients for whom science had little to say in terms of an answer?

Physicians bolstered by their successes with the diseases of "known cause" were very uncomfortable with those patients who did fit into disease categories which were elucidated by the scientific method. Physicians are an uncomfortable lot to begin with, because of the number of unknowns that they have to deal with everyday, even in situations where they are dealing with "well understood" maladies.

When a patient with Fibromyalgia or Chronic Fatigue Syndrome came to a physician in those times, there was first an attempt to understand the pathophysiology of the sufferer’s malady. When attempts to define the cause of the person’s illness failed, there was often a crisis of confidence. The American Model of Scientific Medicine had purported to be able to diagnose and "cure" any disease. In this case, the situation created an environment leading to "cognitive dissonance". In order to relieve this uncomfortable state, the doctor had to either come up with an answer, make one up, or treat the symptoms so as to make himself and/or the patient feel as something "had been done".

This was natural in a paternalistic system. The approach to the patients was not unlike that of parents toward children: give them an answer regardless of its validity, and then prescribe medications that mask or ameliorate the symptoms. This was common practice throughout the 40’s, 50’s, and 60’s. The physician-patient relationship was strong – the patient was told she had "neurasthenia" or "hypoglycemia" or "vapors" or "chemical imbalances" or any number of pseudonymous terms for "I don’t know". But along with these new diagnoses were popular remedies to alleviate the symptoms of pain, lethargy, stiffness, and intermittent confusion.

In 1970, the Nixon Administration pushed through the Drug Abuse Prevention and Control Act. And in 1973, the Drug Enforcement Administration was founded to enforce federal laws regarding the use and distribution of "narcotics", as defined by the Drug Abuse Prevention and Control Act. Many factors led to the 1970 Act and subsequent organization of the DEA, but not least among them was the common physician behavior of treating the symptoms of people with Fibromyalgia and Chronic Fatigue Syndrome with amphetamines, opioids, and sedatives.

Out of a sense of medical impotence, physicians had by a significant majority "overtreated" patients with chronic pain and fatigue. Medical "addiction" was almost commonplace, and many less-than-scrupulous physicians used the patients’ addictions to keep them coming back to the office, and to coerce them to pay their bills.

Now let us leap into the latter 1990’s. Many changes have taken place. Patients have become increasingly sophisticated and educated. Managed Care has overshadowed and overtaken the individual physician’s judgment. When once the physician answered to the court of scientific inquiry, that position is now considered secondary to the directives of the managed care corporation’s profit margins.

Because of the exuberance of yesterday’s doctors and the inability of the Federal Government to control illicit substance use, the Drug Enforcement Agency has focused increased efforts on legal prescription "diversion". This watchfulness by the DEA has elevated physician anxiety regarding the prescription of "narcotic" drugs (as defined by the Drug Abuse Prevention and Control Act).

What is the present day physician’s approach to the patient who walks into her office with concerns related to Fibromyalgia or Chronic Fatigue Syndrome?

You, the patient, come into the physician’s office with need for diagnosis and relief of your symptoms of pain, lethargy, fatigue, sleep disturbance, concentration deficits and muscle stiffness. Most of your symptoms are considered to be controlled by the Central Nervous System (consisting of the brain and spinal cord). Therefore, a neurological evaluation would be considered appropriate in your case.

The physician is presented then with her first hurdle. Let us assume that your physical examination showed "no objective abnormalities" (i.e., there is nothing that the physician sees outside of your verbal report of pain or discomfort). A neurological evaluation might include: EMG/NCV, MRI, CT, EEG, various blood chemistries and antibody evaluations, Evoked Potential studies, and perhaps others. The managed care company will refuse to give approval for these studies because of the lack of "objective evidence" to justify these expensive procedures.

(Also, in many cases physicians are reimbursed, or given incentive, not to perform tests and a percentage of the cost savings are paid to the physician.)

You, as a sufferer of Fibromyalgia or Chronic Fatigue Syndrome, won’t be effected by whether the physician is able to get the tests approved or not; the results will be "negative" because of the limitations of the present technologies. Now the physician faces her second hurdle, what is she going to do with you?

In the former paternalistic system, it was the physicians’ imperative to take care of their patients. The patient had placed her trust in the physician to bring some degree of relief of suffering, and the physician of the age had an unwavering belief that science, most of all biopharmaceutical science, while not always providing a care, could at least quell the extent of suffering. To this extent, the physician-patient relationship was fulfilled; the patient felt better and the physician also felt better because he was not rendered powerless or helpless to aid his patient.

The present system does not allow anywhere near the same degree of latitude. CNS (central nervous system) drugs are often expensive, and are not on the managed care plans’ approved formulary (which means that you, the patient, are responsible for paying the full price for these non-approved medications).

An even more overarching concern on the physician’s part is the DEA’s oversight of their prescribing behaviors. Most CNS drugs used for Fibromyalgia and Chronic Fatigue Syndrome are listed as "controlled substances" by the DEA. The prescribing physician often misunderstands the extent of DEA involvement. This lack of understanding is communicated to the patient. "I can’t prescribe that medication to you because the DEA is watching me like a hawk and I can get into trouble". In fact, the DEA does not record or have a central database that is updated on a daily, monthly or yearly basis. While such centralized databases would be relatively easy to implement and maintain, at the present time they do not consider this part of mission.

Something that is more often the case is that the physician does understand the extent of DEA oversight, but because she doesn’t want to prescribe the medication at all, communicates to the patient that her hands are tied. Whether this is because of concern over addiction, or a concern over the present state medical board position on the use of controlled substances for chronic conditions, or just the fact that she doesn’t like the patient, is not communicated.

Therefore, the nature of the physician-patient relationship is quite different from what it was. Feeling hamstrung by managed care corporations, the DEA, and state/county medical boards/societies, the nature of physician-patient relationship has evolved from the paternalistic to the adversarial.

The adversarial nature of the physician-patient relationship has its underpinnings with the medical liability crises in the 70’s. Malpractice is always in the back of every physician’s mind. However, there is now an amplification of what can be seen as "competitive" behavior between the physician and patient. The patient, no longer someone who is "cared" for, is a consumer of heath care resources, and the physician is no longer the doctor, but a health care "provider".

You then come to the physician’s office not so much now to develop a therapeutic relationship, but rather as a customer. The physician is part sales person and part business owner (or employee), who seeks to make not only the customer happy, but also the regulatory agencies which govern her business (and/or her bosses). As in, for example, a restaurant, if a single customer is unhappy, it is considered unfortunate. However, if that restaurant should make the Health Department, the State Tax Franchise Board, the Alcohol Beverage Control Board, and any number of regulatory agencies unhappy, then they are out of business. Period.

And you, the people with Fibromyalgia or Chronic Fatigue Syndrome, are in the worst situation. You are considered to be inappropriately heavy users of medical resources, and overusers of controlled substances. Given the diametric change in the nature of the physician-patient relationship, what can you do to fortify your position?

You are a customer, and the physician is the "store". The situation is more akin to that of Used Car Lot rather than a retail store, in that bargaining and negotiation skills are paramount. Each side needs to understand the other’s position and then attempt to find a common ground, making a "win-win" for both you the customer and the physician provider.

As a negotiator, you must have objective facts. This means researching your condition, finding medical evidence to support your getting the things that you need, such as diagnostic testing and medications. Your sources must be from "legitimate" publications and authors (i.e., reviewed medical journals or mass media publications that are not considered "fringe").

But the scientific aspects of your negotiations are not enough. The major challenges lay in political and business research. You need to be aware, and enlighten the physician with whom you are negotiating the results of your awareness, of the present stands of the State Medical Board, their county medical society, and the DEA on those things that you want.

You must also have ready information regarding the rules and guidelines of your managed care organization. Those include the policies regarding the drugs which they approve for treating your condition, the tests approved for diagnosing your condition, and the name and qualifications of the initial reviewers as well as the medical director of your managed care plan.

With your scientific, business, and political knowledge you can sit at the negotiation table. With the knowledge you have of your "competitor’s" situation, you should be able to come up with a reasonable compromise. If not, you must, like in any other type of negotiative scenario, leave the table and choose not to do business with that person. However, you must document fully the reasons for your choosing another physician; else you will be seen as a "doctor hopper".

The physician-patient relationship has changed radically. You now have the information and the insights to tackle the challenges of the new "commercial" relationship patients have with their physicians. By using this knowledge, you should be able to maximize your abilities to seek some degree of relief from your chronic conditions.

Copyright © 1998 Thomas W. Shinder, MD.  All Rights Reserved.

Thomas W. Shinder, MD, is a neurologist-turned-network systems engineer who practiced medicine in Texas, Oregon and Arkansas before moving to his present home in the Dallas-Ft. Worth TX metropolitan area.
 

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