There are lots of well-intentioned efforts to improve health care out there. But whether it’s a “patient centered” initiative, a public listing of hospital complication rates or reimbursement linked to patient satisfaction, the subtext is always the same: We’re different from generations past because our patient-doctor relationship is less paternalistic and more transparent.

If only it were that simple.
Robert Truog, M.D.

A recent article by Dr. Robert D. Truog, who is executive director of the Institute for Professionalism and Ethical Practice, describes the larger, and more complex, social forces that have affected the patient-doctor relationship over the last hundred years. Writing in The New England Journal of Medicine, Dr. Truog, who also teaches medical ethics at Harvard Medical School and practices intensive care medicine at Children’s Hospital Boston, eloquently explains that despite the apparent widespread embrace of honesty and openness, both doctors and patients have remained resistant to full transparency — especially when it comes to discussions about costs and the inevitable need to allocate limited health care resources.

“Overcoming our inability to muster the political will and courage to acknowledge the necessity of rationing,” Dr. Truog writes, “and to grapple with the best way to use the tremendous resources currently being devoted to health care is likely to be the greatest challenge in the evolving relationship between physicians and patients in the decades to come.”

I spoke to Dr. Truog recently about transparency between patients and doctors, the challenges to this ideal and the future of the patient-doctor relationship.
Q.

How transparent is the patient-doctor relationship?
A.

We haven’t gone all the way yet. But I’m not sure that patients really want the whole truth all the time, nor that physicians want to provide it. I think a relationship has developed where we as physicians don’t tell patients everything and patients don’t really want to know everything. All of us have colluded in developing a relationship that is not entirely transparent, and I don’t believe that it is really healthy.
Q.

What are the greatest challenges to full transparency between doctors and patients?
A.

I think the biggest challenge by far is the need to make choices that are efficient or, to use a word that has come up a lot recently, parsimonious. That is something physicians don’t want to say and the public doesn’t want to hear. Everyone wants to believe that decisions are all based on medical criteria.

In my field of practice, for example, when a patient is transferred out of the intensive care unit or not admitted to the I.C.U., it’s our practice not to disclose that these decisions may be based on limitations of resources. Those decisions are completely opaque. And no one wants to hear that their loved one is not getting the best because of resource restraints, even if it’s true.

Truly transparent conversations like this paralyze physicians, politicians and patients. President Obama tried to bring it into the debate some years ago, but it quickly became framed as a “death panel” issue. And unfortunately, we doctors have been colluding with the public in the belief that there is some alternative to this conversation.
Q.

How can that level of complete transparency play out in everyday interactions between patients and doctors?
A.

I think being open has been framed as a communication skill, with the problem being in how we teach that skill. Yes, it’s not like you just do an information dump and that’s all; being transparent and open with your patient goes beyond the rote skills of making eye contact, sitting down instead of standing at the bedside and asking certain questions. It comes down to the words we use and the way choices are framed. The way we present or hide our own values is critical and should receive attention.

For example, we videotaped experienced practitioners for a project on how to counsel women when they learn a fetus has a congenital defect. What came up was that these physicians often made the assumption that more information, like getting an amniocentesis and really figuring out what the abnormalities are, is always better. In fact, one of the quotes from a wonderful physician was: “Information is always good.”

But some patients and families really don’t want more information. They feel that if they have the information, they put themselves in the position of playing God. Not having the information spares them from having to make a choice.

Physicians are taught to try to be value-neutral when we have conversations with patients. But more and more research is showing that doctors have many subconscious values. When we try to come across as value-neutral, we may actually be less helpful to families than when we say, “Look, these are the values I have, and I will try to be as transparent as possible about the values I am bringing because I recognize that it may be more useful for you to know where I am coming from than for me to pretend I don’t have values, leaving you to try and figure out what values I am smuggling into the conversation.”

Of course, depending on the circumstances, sometimes we doctors may end up being more paternalistic in some of our conversations. I don’t think that is always wrong. But we do have to own up to the ethical fact that we are being paternalistic as we do it.

I am not suggesting we become paralyzed whenever we present information or choices to patients. We just need to be more self-aware.
Q.

What is the future of the doctor-patient relationship?
A.

I think that we will have no choice but to move toward greater honesty and transparency at all levels, even though both sides are having difficulties with it. But complete transparency is a good thing. I believe we should welcome it in the long run. It’s just that in the short run, it will be painful.