The System Under Stress: Testing the Physician-Patient Relationship

By Sagar Patel, MD; Arush Singh, MD; and Sachin H. Jain, MD

Authors’ Note: This piece focuses on the VA Health Care System.  Thousands of medical students and residents rotate to the VA and as such it is one of the largest federal training opportunities for new doctors.

The first years of medical school incorporate a longitudinal curriculum devoted to the physician-patient relationship. Through early clinical encounters, medical students begin to understand and appreciate the uniquely intimate relationship between physicians, patients, and their families.  Three weeks into our rotation together at the Boston VA Medical Center, our assumptions about the physician-patient relationship were tested.

Mr. R presented to our service with a hip fracture requiring elective orthopedic surgical repair. Upon hearing about Mr. R, we anticipated a predictable hospitalization and course.  Moments after meeting Mr. R and his family, it became obvious that his hospitalization would be far from routine. Mr. R’s family had an instant and obvious mistrust of our medical team—and the reason why was not subtle. Miss R, the patient’s daughter, told us bluntly:

“I did not want my father brought to the VA, and the only reason he is here is at his insistence.  I have been watching the news and I know the kind of %@$ care you give patients here.  Your whole system is under investigation.”

We felt immediately powerless without the trust of Mr. R’s family.

We learned Mr. R’s decision to have his surgery at the VA—when his private insurance would have allowed him to go elsewhere—was based on appreciation for the past experiences he had had at the VA; the comraderie he felt with fellow veterans; and the high level of respect he received from VA physicians, nurses, and ancillary staff.

Miss R felt it was her obligation to protect her father from our hospital. She delved into his clinical management and demanded the discontinuation of several medications we felt were necessary for his recovery.

“I am his health care proxy and I will make these decisions—not you.”

Mr. R’s surgery went uneventfully and we worked daily—and futilely—to build trust with the patient and family. As doubt mounted in media reports about the quality of care delivered by the VA, Mr. R grew more silent and less engaged in his care.

Miss R, it was clear, was in charge. She was in touch with the medical team at least twice a day to review the management of the patient including medication dosing, time of administration, number of analgesic pills required for pain control, and the amount of time the physical therapist spent directly with the patient. Any progress we felt we made by day’s end seemed gone by the following morning.

We held daily meetings with Mr. R and his family to discuss his hospital course. Miss R continued to reiterate her unhappiness with the care provided to their father.

“I am furious at how this Country treats Veterans. Would you treat your family member this way?”

When we gently asked about what specifically we could do to make things better, she would not engage us: “I want him transferred to another hospital.” 

When we encouraged transfer to a rehabilitation facility where he could receive aggressive physical therapy, she feared we were sending him to a nursing home to die. Nothing we said would allay her fears.

Miss R remained unable to articulate what specifically bothered her about the care her father received, other than to say that she knew intuitively that his care would have been better if had been delivered anywhere other than our hospital, under the care of any physicians other than ourselves.

In our frustration with the situation, it became clear to us that our notion about the physician-patient relationship—a relationship that is painstakingly built through competence and sound communication—was incomplete.  Trust in the system in which one receives care is a hidden but necessary element that is implicit in any physician-patient interaction. When trust in the system is lost, there is often little a physician can do individually to regain it. He or she is perpetually working from behind.

Fortunately, Mr. R’s daughter was the exception and not the rule, and even Mr. R’s belief in the care he received never wavered.  As he neared readiness for discharge he expressed his thanks.

The other patients on our service seemed to be unperturbed by the media coverage surrounding some of the systems issues within VA. Seemingly prompted to reassure us of their confidence in their care, one patient on our service remarked simply, “I wouldn’t go anywhere else.”

Patel Sagar

Sagar Patel, MD, is an intern physician at Brigham and Women’s Hospital.

Arush Singh

Arush Singh, MD, is a resident physician at Boston Medical Center.

Sachin_Jain

Sachin H. Jain, MD, is an attending physician at the Boston VA Medical Center.

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