The silent world of doctors and patients

That's the title of a book by Jay Katz, written maybe 20 years ago. It's less true than it used to be, I suppose, but there's still a significant gulf much of the time. Without going into more detail than I'm allowed to until we get the work published, I will say that in our work here I'm finding more and more that important issues are unlikely to be discussed in routine office visits unless they are forced onto the agenda by some form of intervention. It turns out that this includes not only people's non-adherence to prescribed medications, but also emotional distress and the causes of such distress in patients' lives.

The latter aren't necessarily the province of the physician to solve, and it's quite possible that a patient might not particularly want to share them with the doctor, but there are also many reasons why leaving them out of the medical space can be problematic. For one thing, people who are interested in measuring the outcomes of medical care, and who want to do it in a "patient-centered" way, such as my colleague John Ware, will ordinarily ask people about their well-being and functional status. The answers don't just depend on the physician's measures of health and illness such as laboratory tests and x-ray images: they are all about how the person is getting along in the world. After all, that's what a patient-centered doctor wants to support.

For another thing, people who are stressed out, depressed, or anxious are a) likely to be in poorer health because the emotional stress wears down the body, and b) likely not to engage as effectively in self care -- such as following medication regimens -- as people who are feeling good about themselves. And of course, people who are in distress may be in some sort of physical danger or material want, or they may have treatable mental disorders, all of which are relevant for physicians.

So, while respecting boundaries and the finite scope of the professional relationship between doctor and patient, there is a case to be made for a relationship in which patients can disclose and share personal information and feelings which are not strictly in the biomedical realm. This is called a bio-psycho-social model of medicine.

If it really is what we ought to be doing, we still aren't very good at it. On the other hand, there are people who object to the "medicalization" of more and more realms of life and see physician intrusion into these realms as potentially diminishing our autonomy and redefining human experience in damaging ways. These are actually difficult questions. What do you think?