The importance of the doctor-patient relationship, and why we can't have it anymore 

Why it's important 

One-day, down on your luck and in need of some quick cash, you decide to rob a Seven-Eleven.  You rush in brandishing a .38, and order the clerk to hand over all the cash.  He turns out to be a wise guy, so you shoot him. You quickly clean out the register and head for the door - where you run smack into two burly police officers who happen to be entering the store right then for some of that good Seven-Eleven coffee.  You are quickly and none-too-gently disarmed and arrested.

So there you are - caught red-handed, money in one hand, gun in the other, the blood of the clerk on your shirt, and the whole thing recorded, in living color, by a hidden video camera.

Now, here's the question: What rights are you entitled to?

Despite the fact that anybody can see how guilty you are, you have many rights.  You have the right to a fair trial.  You have the right to be considered innocent until a jury of your peers declares you guilty.  And you have the right to appeal the verdict (assuming, of course, that you won't like it).

But most importantly and above all else, you have the right to counsel, an advocate, an individual who is obligated to defend you against all odds, to the best of his or her abilities, and to protect your interests against the world.

Many physicians find themselves envious of the unbending resolve with which lawyers are able to embrace their most basic role of advocacy.  Lawyers retain this luxury because society recognizes the legal system to be a morass of rules and regulations which ordinary citizens cannot hope to navigate on their own.  Any citizen who becomes embroiled in this morass is universally acknowledged to have the right to a lawyer who is expected to hold that citizen's interests above all others (within, of course, the constraints of the law).  Even those accused of the most heinous of crimes are entitled to legal representation, and even if the evidence against them seems overwhelming, their lawyers are expected to jealously guard their rights.  While the rest of us may become frustrated and angry when we observe the rights that accrue to (in our eyes) an obviously guilty party, on an objective level most of us understand the wisdom of such a system.  And we shudder to think of the abuses that would occur if these protections were removed.

When you are sick, shouldn't you be entitled to the same protections as when you rob a 7-eleven?

Most of us think so.

Sick people are no more capable of navigating the complex healthcare system than are accused felons the complex legal system, and are no less in peril if they run afoul of that system.  And a patient's need of an advocate, a professional whose job it is to protect the patient's own best interests against the conflicting aims of the "system," is no less vital than that of the felon. When you are sick, you should be entitled to at least the same protections as when you rob a Seven-Eleven.  And the doctor-patient relationship is supposed to see that you are.

Over the ages the doctor-patient relationship has been defined, through rules of ethics and rules of law, as a fiduciary one, as a relationship founded in trust. When a patient seeks a physician's help and the physician agrees to give that help, a special covenant is made.  The patient agrees to take the physician into her confidence, to reveal to him even the most secret and intimate information related to her health.  The physician, in turn, agrees to honor that trust, and to become the patient's advocate in all matters related to her health, placing her interests above all others - including his own personal or financial concerns.

Now, to be sure, the doctor-patient relationship was never completely pure in actual practice, even in "the good old days."  But a strong fiduciary relationship has been what patients have expected, what most doctors have striven for, and what everyone else (the medical ethicists, professional societies, and those who write and enforce the laws of the land) have traditionally agreed - and even demanded - should be the standard.  It represents the fundamental expectation of how doctors and patients are supposed to behave toward one another.  

The loss of this doctor-patient relationship has obvious consequences for patients.  Patients, when they are sick and thus least able to fend for themselves, are left without a true, dedicated advocate as they try to navigate the hostile halls of the healthcare system.  Most doctors still try their hardest to do what's best for their patients, but they can only do so within the constraint of needing to maintain their ability to practice medicine; and such constraints often are not trivial.  Loss of the traditional doctor-patient compact leaves patients marginalized and floundering at the time they are most vulnerable.

Less obvious, but no less profound, are the consequences of a destroyed doctor-patient relationship to the profession of medicine.  Abandoning that relationship means that physicians have committed the "original sin." They have abdicated their traditional, ethical, and legal roles as patient advocates; they have broken a sacred pact. They have fully compromised themselves as professionals, and as a result, to their utter frustration, find themselves standing naked before their enemies - the very enemies who forced this abdication.

Thus, the traditional doctor-patient relationship is vital to the professional survival of the physician, and to the physical survival of the patient.  If we lose this relationship, we lose everything.