Emancipated Patients and a New Kind of Doctor

by
Ivan Wolffers, MD PhD

This article was originally published in the Dutch language and translated by MeTZelf.
We wish to especially thank Dr. Wolffers for permission to reprint it.

Information, interests, and independence within medicine do not always converge. Knowledge which others do not possess creates the others' dependence. Knowledge is the intellectual’s capital. Doesn’t it make good sense that a person doesn’t give his money away? Sharing knowledge means you lose it, you no longer have the exclusive right to it, so you lose income. On the health care market, the doctor is benefited by the consumer’s lack of knowledge. An assertive patient is not most physicians’ favorite. He will ask more questions and not always be satisfied with just any answer.

Experts’ greater knowledge is ritualized through use of words that outsiders cannot understand. Medical jargon – a mixture of Latin, Greek, and English [also in the non-English speaking world] that includes more terms than a standard dictionary – is recorded in medical lexicons that expand evermore with each edition. There’s even a lexicon of medical abbreviations only, 13,000 of them. Some concepts are represented by as many as eighty synonyms. Perhaps here the linguistic law is applies: the less a thing is understood, the more words there are for it.

Many words in medicine are designed to disguise uncertainty or ignorance. Analyses of physicians’ use of language reveal that much of it is vague, evasive, and unintelligible. The profession is jeopardized when patients’ knowledge exceeds physicians’. Patients’ knowledge has to be defused. What is a physician to do with people who bring a printout from the Internet to their appointment? The average physician does not have so much time to read a lot about one specific symptom. Patients are told that there is a great deal of nonsense on the Internet.

When in 1976 I started writing a daily column in one of the country’s leading newspapers, many physicians complained that such information would undermine the confidential relationship between the physician and the patient. They meant that the patient might have less confidence in the unlimited power of the physician, and that therefore the latter would be called on to explain and justify more.

A new kind of patient has arisen: the emancipated, informed user who is capable of making responsible choices on the health care market. This calls for a new kind of physician. In September, 1999, the British Medical Journal published a special edition entitled, “It takes two.” The market model, in which the consumer increasingly has to make conscious choices from among various health care packages, treatments, and risk profiles, means that the physician is no longer the one who attends to our health. Consumers have become managers of their own health. In this new relationship, the physician is the primary consultant, someone who provides quality data so that the patient can make informed choices.

Are physicians capable of doing this? Are they prepared for it? Can physicians disentangle themselves from the conflicts of interest that have developed in the course of time with the manufacturers of medicines? Already very long now, the pharmaceutical industry not only produces drugs, but increasingly promotes illnesses. It dominates scientific developments in that area, providing information on all levels, and in the end supplying the drugs. It starts by marketing a problem. Renowned scientists are bought for this purpose. They are not only enlisted to educate colleagues about the understated problem, but are also dispatched to important meetings to ask questions about medicines, creating the illusion that there have been spectacular new developments which no physician would want to miss. The physicians whom they seek to persuade are generally sponsored to attend such meetings. They are also involved in research on new drugs. The protocol has been designed in advance. By now we know that sponsored research is biased. Meanwhile the state is reducing its role in funding pharmaceutical research, leaving a lot of sponsored research and very little independent research. Evidence-based medicine rests mainly on the research desired by the manufacturers of the drugs, not the issues that interest health care consumers.

I believe in the assertive patient, and I believe that medical science has a lot of important things to offer. But I doubt that what we have here is merely a tango. The relationship between the dancers is uncomfortable. In my opinion they are more like spouses in a bad marriage deciding to take dancing lessons. A good instructor may save the marriage.