The other day I came across this photo of a couple clasping each other in a dramatic tango on the cover of an old medical journal, a special issue from 1999 that was focused entirely on doctor-patient partnership. The tone and subjects of the articles, letters and editorials were identical to those written today on the topic: "It’s time for the paternalism of the relationship between doctors and patients to be transformed into a partnership;" "There are benefits to this change and dangers to maintaining the status quo;" "Some doctors and patients resist the change and some embrace it: Why?"
Two questions struck me as I impatiently scanned the articles from 12 years ago: First, why are these articles about doctor-patient partnership still so relevant? And second, why did the editor choose this cover image?
I’ve been mulling over these questions for a couple days, and I think an answer to the second question sheds light on the first. Here are some thoughts about the relationship between patients and doctors (and nurse practitioners and other clinicians) evoked by that image of the two elegant people dancing together:
It takes two to tango. Ever seen one guy doing the tango? Nope. Whatever he’s doing out there on the dance floor, that’s not tango. Without both dancers, there is no tango. The reason my doctor and I come together is our shared purpose of curing my illness or easing my pain. We bring different skills, perspectives and needs to this interaction. When in a partnership, I describe my symptoms and recount my history. I talk about my values and priorities. I say what I am able and willing to do for myself and what I am not. My doctor has knowledge about my disease and experience treating it in people like me; she explains risks and tradeoffs of different approaches and tailors her use of drugs, devices, and procedures to meet my needs and my preferences. Both of us recognize that without the active commitment of the other we can’t reach our shared goal: To help me live as well as I can for as long as I can.
Each dancer adjusts to his or her partner. In tango, each partner has different moves; the lead shifts subtly and constantly between them throughout the dance. In a partnership, when I am really ill, I delegate more decisions to my physicians; when I am well we freely go back and forth, discussing treatment options and making plans.
Both dancers have to want to dance. One dancer is not familiar with the music and holds back, reluctant to look foolish; another woodenly goes through the motions, dancing with her father-in-law out of obligation. If my doctor doesn’t indicate that she is interested in listening to me--doesn’t invite my contribution to a discussion, answer my questions or address my concerns--chances are we won’t be having much of a partnership. If I believe my doctor can diagnose me based on a few tests, cure me by prescribing a few pills and that she will tell me everything I should to know--I need only do what she’s told me to--the chances of us building a strong working relationship are low.
Everybody has to learn to dance. No one is born knowing how to tango. You have to learn the steps and practice them over time. We witnessed the deference our parents accorded our physicians and most of us have had few opportunities to behave differently, either because we are pretty healthy and have little contact with health professionals or because we are pretty sick and we have other things on our mind at the time. Similarly, most doctors practicing today trained with physicians who expected considerable deference from their patients. The saying, "Just because you have furniture doesn’t mean you are an interior designer" applies: Just because you can talk doesn’t mean you know how to build a partnership where it is possible to openly discuss intimate bodily functions, symptoms, drugs, hope, depression, fear, life, death, and what might be done to ease the suffering with this relative stranger. Building and maintaining a partnership between a doctor and patient constitutes a dramatic change in power, responsibility and ways of interacting. Making those changes requires that both partners learn to listen, talk and act in ways that are unfamiliar and often uncomfortable.
There’s no revenue model for dancing. Unless they win "Dancing With the Stars" or work tirelessly to become professional ballroom dancers, most people who tango receive no financial reward for their efforts. They dance because it is satisfying; because they love the music or the feeling it gives them or the joy of mastery or the fancy outfit. No one will pay me or my doctor to forge a partnership with each other, although it is possible that one barrier to my doctor doing so, lack of time, will be removed by being better compensated in the future. But no policy, incentive program, or performance measure is likely to induce either of us to interact differently. We will only change the way we communicate because we see value in doing it and because we see risk of harm in not doing it. We will change because we respect what each other knows and needs in order to do his or her best. And we will change because we realize that only by communicating as partners can we reach the goal we share, my improved health.
Viewing the relationship between doctors and patients through the lens of these dancers, I am reminded of the flexibility and sensitivity required of both doctors and patients, working as partners, to accommodate the ebb and flow of illness. These new communication skills can only be learned through practice in the company of a partner who is similarly committed to using them. Partnerships between patients and their providers are driven not by financial incentives or punishments but because we both realize that it is no longer safe or feasible to deliver or receive the full benefit of healthcare without them.
And so while I’m disappointed, I’m not discouraged by the relevance of the dated articles in the journal with the dancers on the cover. Moving from paternalism to partnership between doctors and patients constitutes a huge shift in attitude and practice for all of us. That shift is difficult for many and as a result, its pace has been, to quote CMS director Don Berwick, "majestic." The public and professional media cover healthcare reform, public health program cutbacks, daily advances in medicine drugs and technology, demands of evidence-based medicine, and the reorganization of care, reflecting the priorities of those within healthcare. So I am grateful for every journal article, training program, or conference announcement and media campaign that sends up the flag to remind us and our doctors that it is only through our partnerships with one another that we will receive--and they will deliver--the best care.
I may not be discouraged, but I am still impatient. Come on! The music is playing. It’s time for all of us to start dancing.
[Editor's note: A similar cover image was chosen by the British Medical Journal (BMJ) for their February 7, 2009 issue titled "Reframing Relations with Pharma: It Takes Two to Tango."]
This post by Jessie Gruman, PhD, appeared at Get Better Health, a network of popular health bloggers brought together by Val Jones, MD. Better Health's mission is to support and promote health care professional bloggers, provide insightful and trustworthy health commentary, and help to inform health policy makers about the provider point of view on health care reform, science, research and patient care.