When my father reached his mid-80s, an accelerating accumulation of physical and mental functioning issues persuaded him to switch to a primary care physician in a concierge medical practice.
Although the doctor’s pedigree proclaimed his competence, he mostly excelled as the medical equivalent of a hotel concierge who can magically procure hard-to-get restaurant reservations at the last minute. The doctor would see my dad on short notice and make sure he quickly received various diagnostic tests or appointments with specialists. My dad trusted him; my siblings and I were less impressed with the medical rationale behind each flurry of activity.
I thought of my father’s experience when reading a new study of community-dwelling older adults. It concluded that older patients “view their physicians as serving advocate functions on patients’ behalf.”
To the authors’ surprise, an overwhelming 87 percent of the participants abjured the “empowerment paradigm.” Instead, the study concluded that elderly patients “believe in the empathic commitment of their doctors to promote patients’ well-being and trust that their physicians will represent their best interests.”
Does that mean we should go back to treating the physician more as pater familiasthan partner? Not quite. The results serve more as a reminder that as individuals we often gravitate to simple answers even though our lives tell a more complex story.
To begin with, “elderly patient” is a generalization that begs for specifics. In this case, the average patient was 78 years old. About half had a high school education or less and four in ten rated their own health as “poor/fair.” About one in four were African-Americans or Hispanics. We shouldn’t forget that education, race, gender and ethnicity affect both our relationship with and expectations of the health care system. For many patients, prioritizing a doctor who can help “navigate the system” is eminently sensible.
And frankly, navigational savvy can also make a lot of sense for those of us who are white, younger, in better health and more educated. I wrote about my hernia surgery a couple of years ago in a blog post entitled, “My Surgical Shared Decision: Trust the Doctor.” My personal attempt at the time to practice “empowerment” taught me that there are some treatment decisions where it’s important to ask questions, but there are others where the smart move is trust your doctor. So, for example, my attempts at researching the choice of surgical mesh were utterly futile.
Different ways to foster partnership
Letting the doctor do some of the heavy lifting is not the same thing as passivity. Intriguingly, the study of elderly patients suggests that positing the physician as navigator may be “a subtler form of participation that is intended to be respectful of health care providers and intended to foster partnerships with them.”
One variable the study doesn’t capture is the influence of adult children. That concierge doctor my father chose was of no use in trying to find home care aides or an independent living facility or, in the opinion of my siblings and me, in a lot of other areas. So we eventually persuaded our dad to switch to a different concierge physician at a different practice who was a lot better partner.
Meanwhile, the elderly population itself will increasingly feel the influence of the Baby Boomers. The recent annual conference of the Society for Participatory Medicine (SPM) honored a 68-year old cancer survivor known internationally for his advocacy of patient empowerment, online information and a relationship of equals between doctors and patients. E-patient Dave,the preferred moniker of Dave deBronkart, was recognized along with the primary care physician who helped him find the online information central to his survival, Dr. Danny Sands.
Patient autonomy vs. physician as advocate doesn’t have to be an either/or proposition.Complexity and nuance are what give the clinician-patient relationship texture and richness.
