The New Participant in the Doctor-Patient Relationship

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The doctor-patient relationship is the foundation upon which our health care is built. Over my 30-year career as a surgeon, I observed a profound change in this relationship that does not get a lot of attention — but has a lasting impact. Money has formally entered the doctor-patient relationship. It’s the new silent partner that deserves a voice.

I decided to become a physician while I was a graduate student, and I faced a life-threatening emergency. I was bleeding internally, and without the surgeon’s care, my life would have been snuffed out in my early 20s.

I had excellent insurance, and my total out-of-pocket expenses for this life-saving intervention were less than $100.

I remember laughing as I reviewed the bills from my hospitalization. Four dollars for an aspirin! But it didn’t matter because all of the medical bills were paid with what felt like Monopoly money.

As I launched into my own career as a practicing surgeon, my focus was on patient care. I simply did not talk about money with my patients — until one day when one of my patients opened my eyes. I prescribed a new antibiotic for him because he experienced serious side effects from the standard antibiotic. He said to me in followup, “Dr. Rackner, do you know how much that prescription costs? Over $100!” In a moment of humility, I became aware that I knew very little about how much patients paid out-of-pocket for health care. This was the 1990s, when the economy was booming.

I saw that my patient would have made different choices had he known what the medication cost.

As a pet owner, I am intimately familiar with the pain of out-of-pocket medical expenditures.

Just last year my dog had a rapidly growing mass on his leg, and my fear was that he had cancer. My vet recommended that she biopsy the mass, find out what it was, and then make a treatment plan. Then, as always, she was transparent about the costs because her bills are not paid with Monopoly money; they are paid with the hard-earned dollars of hard-working pet owners. She knows that treatment costs can and do impact the choices people make about their pets’ care.

I gently asked, “Is there any finding from the biopsy that would change your plan about how you remove the mass?” She thought for a minute and said, “I see your point.” We collaboratively decided to skip the biopsy, and I saved about $1,000. And my dog is fine. This was an inflammatory mass.

Just to be clear, I am not suggesting that humans skip biopsies. In our species, a biopsy does make a difference in the therapeutic plan.

However, in humans, it’s more difficult to have the kind of conversations I have with my vet — in large part because it’s difficult for doctors and patients to have conversations around money. Had my dog had insurance, I’m not sure I would have questioned the value of the biopsy.

The reality is that patients have much more financial skin in the game than when I launched my career. Costs can and do enter into decisions about whether patients follow their doctors’ suggestions.

Another sad reality is that we as a nation are still recovering from our financial crisis. A Federal Reserve report found that 40% of Americans would have to borrow to pay a $400 emergency bill.   

It’s time for doctors and patients to have more conversations about medical costs, just like my vet and I do.

It’s time for more doctors to ask their patients, “Can you afford this medication?” Some pediatricians now ask parents, “Can you afford to feed your kids?”

It’s time for more patients to ask their doctors, “What is my out-of-pocket expenditure for your recommended plan, and is there a lower cost option?”

Doctors and patients routinely engage in a process called “informed consent” in which patients weigh potential risks and benefits to make truly informed choices. It’s time for costs to become a routine part of this conversation.

Money is the new silent partner in the doctor-patient relationship, and money matters. Let’s give it a voice.

Vicki Rackner, MD, FACS, calls on her experience as a practicing surgeon, clinical faculty at the University of Washington School of Medicine, and entrepreneur to fuel her curiosity about doctors and their relationship with money. Her latest book is “The Myth of the Rich Doctor.” Dr. Rackner will be speaking to physicians in an upcoming speaking tour throughout the Rio Grande Valley. Contact Ed Sokolosky with United Capital to find out more at (956) 792-0167  or visit doctoreventsrgv.eventbrite.com.