Book Review by Pamela Stephens

5.0 out of 5 stars Review of Dr. Hamner's book. Reviewed in the United States on March 26, 2021

Book Review - Rescuing the Doctor-Patient Relationship
Esteemed nephrologist Ronald W. Hamner, M.D., recently decried that the doctor-patient relationship is on life support in his new book Rescuing the Doctor-Patient Relationship. In the past he asserts the physician offered “comfort-based care rather than chronic care for most diseases.” However, with the advent of government regulation, lobbying, the cost of pharmaceutical innovation, patient health insurance providers, medical device inventions, and increased patient long-life, costs have escalated causing treatment to be based on a business model. These costs, charges, and changes have affected the doctor-patient relationship adversely.
Examining the situation from a perspective based on 37 years of serving patients as a kidney specialist and as CEO for eight years of a large Texas nephrology practice, Dr. Hamner approaches the subject as a care giver and as a financial analyst with an eye on history.
Although the doctor-patient relationship includes a legal contractual component primarily through payment arrangements, it also is affected by other economic, professional, and personal factors. For example, patients may welcome or decline services and medications based on budgetary considerations or opt to use the less personal choice of an Emergency Room visit where a co-pay is not required. In turn, some practices may turn away Medicaid patients because scheduled physician costs, and fees--usually the result of agreement between the practice and third-party payers--must be met to ensure the continuing financial stability of the practice. Often the patient remains clueless as to cost of services until a significant time period has elapsed after treatment. Occasionally the patient and the doctor decide on a specific fee for service as in concierge plans or the doctor receives a salary as an employee. In the latter scenario, timed physician-patient appointments diminish the doctor-patient relationship as well as those visits that occur in teaching hospitals or government instituted clinics where physicians rotate, thereby interfering with the patient’s seeing the same physician on a continuum.
Professionalism also imbues the doctor-patient relationship. As a healer, not only competence but also “commitment to the therapeutic and best personal interests of the patient”; “protectiveness for the patient against payer, provider and occasionally, patients’ counterproductive demands,” “fierceness” in protecting the patient against useless therapy come into play.
Finally, personal factors infuse the doctor-patient relationship, with the patient advocating for being recognized for his uniqueness.
Increased demand for medical services has evolved along with life expectancy, and employers’ thrust for wellness in the work place has been construed as a patient right. Expectations levels also have risen as the population looks to research and development, vaccines, screenings, and novel therapies to extend life in the face of complex diseases. Moreover, third party payees often police whether doctor-ordered tests can proceed, thereby creating friction between doctor and patient.
Dr. Hamner asserts that health care chaos has resulted from other factors as well. The Affordable Care Act has reduced the number of participant insurers, physician payments, and coverage yet escalated premiums, deductible costs, and out-of-pocket expenses. Legislation such as the HITECH Act of 2009 that federally mandated electronic medical records has raised practice overhead, eaten into physicians’ face time with patients, diminished productivity and availability, and reduced specificity in medical records to often unhelpful generic statements that may be further impaired by misspellings.
To eschew such chaos, reforms need to occur. First, health care has changed from an acute model to chronic disease management. Second, payment systems need to elongate to manage the chronic component and replace the “single point-of-service” bill. Third, portability must occur in medical records. Fourth, “competitive pricing and availability” need to emerge. Fifth, there must be a medical care team approach with “the expert in the patient’s current disease state” as captain. Sixth, the patient must participate actively. Seventh, payers should not “micromanage medical treatment and costs.” Eighth, more flexibility should earmark medical facilities. Ninth, patient affordability must be available in medications and therapies.
Such changes would need recourse to federal law, state legislation, patient education, healthcare facilities and systems, pharmaceutical attitudes and revised payment systems that Dr. Hamner details.
The final chapter of his book assesses the societal intrusion of Covid-19 within the doctor-patient concert.
This meticulously researched scholarly book with 265 footnotes and 245 bibliographic entries is a timely resource not only for physicians and other hearth care professionals, but also for government officials, insurers policy makers, pharmaceutical entities, educators, and American citizens concerned with the burgeoning costs and quality of health care.
In short, the doctor-patient relationship may be on life support. No band-aid approach will work, but a multi-pronged approach may rescue the situation.