Is Your Doctor Your Doctor?

I used to believe that there was such a thing as “the doctor patient relationship”. Maybe a long time ago and if you are a patient and are lucky you may have a doctor who you know and who works for you without being encumbered by a relationship with an insurance company or a “health care network. But for 90% of us—me and my wife included that is not the case. We signed up for a Medicare Advantage plan with United Health and they have assigned us a doctor. My doctor seems like a great guy. Like me he likes sports and the outdoors. He is a family man with three children. I know who he is because his name is listed on the front of my Medicare Advantage Card. I am sure if the group of doctors who have taken care of me and my family for years were part of this particular network, I could ask that they be my primary care physicians—I will do that next week. Who knows?

I have read in the news and heard on the radio people complaining that “their doctors” won’t give them hydroxychloroquine or Ivermectin or some other therapy. So without getting into The Code of Ethics of any professional organization and I will skirt around a legal issue that involved me, I would like to make a few comments and observations.

Traditionally the doctor patient relationship was entered into willingly by both parties. It is not a marriage. Either party can remove themselves from the relationship at any time, though there is a burden on the doctor to secure further care for the patient should the original relationship dissolve. The patient could fire the doctor and the doctor could fire the patient. The patient cannot force the doctor to prescribe a medicine or perform a procedure. The doctor cannot force a patient into a procedure or force them to take a drug against their consent. The doctor must follow his/her own conscience. They are responsible for recommendations they make that involve their own patients. Opinions that doctors have about health care issues in general where a doctor patient relationship does not exist are now being tested as being a part of the practice of medicine by several State Boards of Medicine—including Oregon and Washington State. In each State a physician has lost their license to practice medicine because of opinions about Covid treatments that are not in line with public health directives. Even in our State a former Idaho Attorney General Mr. (Dr.) Jim Jones has opined in an editorial that this should be the case though he admits that Idaho Law says otherwise. If this were the case every time an Idaho doctor prescribed a medication off label, or a retired physician offered an interview to a reporter and offered a medical opinion without having a current license to practice in the State of Idaho, their license to practice medicine would be in jeopardy in the 1^st case and in the second case they would be practicing medicine without a license. Federal Courts understand this and have ruled in favor of physicians in almost all cases. They have also ruled that only doctors can practice medicine and not hospitals or insurance companies. The standard and the practice of the relationship between employed private practice physicians and hospitals needs further clarification in Idaho. Watch IACI.IMA.IHA, and even The BAR, to come out strongly in favor of a hospital centered paradigm—patients and doctors will be left behind—they almost already are.

Doctors today value the relationships they have with their patients as their predecessors did, but many don’t understand how the relationship has changed. Neither do others in the insurance and hospital industries. For doctors and patients, a central question should be who pays for the services that are being provided? In times past the professional and business relationship was between the two parties—doctor and patient. If the doctor is employed by a hospital system, he is paid by his employer. If the patient has engaged an insurance company, then the insurance company is the payer. If the patient is covered by a government program like 55% of Americans are, then in most cases the government will pay a price for not only the care of the patient, but will pay an insurance company to manage the program. Many large employers do the same thing—they take the risk and pay for the administrative fees. Every now and then companies and some States, the States almost always fail, the companies sometimes, take on both the risk and the management of a program.

4In 1995 I was on trauma call at St. Al’s when a Native American Chief was brought into St. Al’s. He had been a heavy smoker and apparently in his role as a “mystic” had used peyote often. Though in shock the tribal members and family that were surrounding his bed wanted to use peyote in the ICU and give him what I thought to be a massive dose, well over the LD50—the dose that would kill 50% of patients. As his doctor I was obligated by “privilege of the relationship” to do what I thought was best for the patient—not what he or his family wanted. This was late on a Sunday night. By 4AM the hospital attorney, a hospital Chaplin, CEO, a magistrate judge who turned out to be very wise, figured out a solution—this could have been far more complicated legally than it ended up. I agreed to care for the patient until another doctor assigned by the hospital (a solution I offered 4 hours earlier) —a hospital employee would take care of the patient. Until then I would follow the dictates of my conscience. It took 15mins after the order to find another doctor. The patient got his PCP, and so did those at the bedside. I should not tell the rest of the story because of HIPPA concerns.

The CEO at the time was a Catholic Sister who honored the doctor patient relationship. As the years went by, she became a close family friend, even performing a Rosary for my mother-in-law. But I today wonder what would happen if a Covid patient insisted on getting Ivermectin, or an experimental off label medication in the same ICU. Would the same process play out? What would happen if a doctor did recommend and then prescribe a course of therapy that was not “within the clinical guidelines”? Remember that clinical guidelines help define a “standard of care”. The standard of care is different than the “standard of medical practice”—what is done in a community. Mr. (Dr.) Jones should know this.

If you are a patient no matter what you have read, you do not have the right to insist that your doctor follow a course of therapy that is against their medical judgement or against their conscience. If you are an employer—hospital, the terms under which you can leverage a doctor to act in a particular fashion may be different. In either case the doctor patient relationship is not as simple as it used to be either in professional or economic terms. The role of doctor as employee, and hospital as doctor needs to be addressed by the legislature before a court or a bureaucrat usurps that authority and redefines the rules—are arbitrary and capricious and haphazard the same thing? I will leave that up to people smarter than me—like Dr. (Mr.) Jones to figure that out. Issues of licensing and credentialing need to be reexamined. As long as there is a big grey area—actually in our State a “black hole”, the doctor patient relationship will further succumb to the ambiguity of the rules and the whims of those who have little skin in the game.