Friends, not enemies
The asymmetry between patient and doctor is not only a question of information transparency, it is also a problem of basic knowledge and understanding.
The non-governmental Taiwan Health Reform Foundation was founded in 2000 to help out on the patients' side of this (im)balance, to create an opportunity for dialogue between doctors and patients.
Over the past four years, the THRF has played the role of "whistle blower," drawing attention to many problems. Though some medical professionals consider the foundation a "plague," and say that it is just a bunch of outsiders criticizing something they don't understand, THRF chairwoman Chang Ly-yun, a sociologist by training, replies, "If we were trying to treat patients, of course we would be outsiders, but who can possibly remain outside of health care as a public matter?" The foundation simply seeks to smash the arrogance and absurdity of those in the medical community who think, "if you don't understand the science, you have no right to have an opinion on the health care system."
"It is simply that THRF has adopted a perspective that is different from that of doctors, but we are not opposing ourselves to them!" This sentence, it seems, could apply equally well to the relations between doctors and patients. Chang believes that the best way to improve the quality of health care in Taiwan is to let patients participate more. This will also become one link in the chain of preventive medicine.
"The purpose of providing patients with basic treatment information, such as labels on prescription medicines, access to their own medical histories, and agreement forms for surgery, is to allow patients to understand what doctors are doing. Because if by chance the doctors or nurses make a mistake, this is the only way the patient will have a chance to find out what really happened." Chang emphasizes that this "empowerment" of patients is not a challenge to or attempt to seize authority, but is a measure to prevent the occurrence of even more serious medical mistakes.
However, coordination, participation, and discussion require an accommodating environment. "How many hospitals have the time or space to let doctors and patients really talk?" queries Chang.
In recent years doctors have been encouraging patients faced with major decisions to seek "a second opinion." But in practice this is very difficult. The main obstacle is acquisition of medical records.
Chang Ly-yun points out that few ordinary people have the tools to accurately describe their conditions; they need help from test results and patient histories. But patients who want to access their own records now have to tell a lie-it is almost impossible to succeed unless they are requesting the records "on behalf of the insurance provider."
"If we could follow the American model, in which hospitals have a duty to provide medical records to patients, then we wouldn't need to put the burden on the patients. What's more, when a medical professional knows that what they write on the charts is going to perhaps be reviewed by one of their peers, they will be more careful and precise in what they write."
On top of medical records, in the future the THRF will propose the creation of "pharmaceutical records." Chang says that if a patient has to visit several departments, there can sometimes be duplication of prescriptions, or even prescribing of drugs that will, taken together, have severe side effects. If each patient has a "pharmaceutical record" to carry around, doctors in different departments can take into account what other doctors have decided, and make the necessary adjustments.
Soft revolution
In contrast to the more abrasive approach of the THRF, Michael Chung is more inclined to a "gentle revolution" based on self reflection and learning in the medical community itself. "After all, we still need doctors-don't scare them off!"
As accusations and criticisms criss-cross back and forth, some in the medical profession believe it is necessary to step back and gain some perspective on the issues.
Li Yuan-te, former head of National Taiwan University Hospital and now a professor at NTU's College of Medicine, has pointed out in a published article that a German magazine on family medicine has praised Taiwan as being "an exemplary model despite being kept outside the WHO," the ABC television network in the US has called Taiwan "a health utopia," and health care services in Taiwan are ranked second among OECD countries. "Each day in Taiwan there are 780,000 medical consultations," says Li, "and each year there are 2.88 million hospital stays. Isn't it being much too negative just to pick out the 200 medical disputes and thereby obscure the vast contributions made by the medical profession?"
A patient-doctor treaty
Be that as it may, it is also true that in recent years even many members of the medical community have begun to reflect on the problems in the system.
For example, there have been efforts to clarify in both theory and nomenclature the relationship between doctors and patients. Whereas Taiwanese have always used the expression "doctor-patient relations," these days there is a quiet shift to the term "patient-doctor relations."
"The patient-doctor relationship is a very intimate relationship," says Andrew Huang of the SYSCC, who returned to Taiwan 16 years ago. To construct an intimate relationship of this nature, "doctors have to lead the way by being the first to change."
In July 2003 at a conference on health care in the wake of SARS, Huang began to promote the idea of a patient-doctor alliance, complete with a "patient-doctor agreement." Such an agreement would read, in part, "As doctors, to whom patients entrust their lives, we will do all we can to relieve the patient's pain, and contribute all we can to promote the health of the patient. We will listen carefully to the patient's complaints, inquire in detail to get the complete medical history, and use caution in undertaking essential tests and procedures, and will also exchange views with other doctors.... We will leave no stone unturned to explain to each patient his or her medical condition, to respond to questions, and to resolve doubts, and we will aim to help each patient gain complete understanding.... We will not accept grants or profit shares from hospitals, pharmaceuticals manufacturers, or other businesses, which would require us to use specific methods to treat patients.... We believe that the dignity of the medical profession and the trust of the public come from our own commitment as doctors to keep in mind and to put into practice our professional oaths."
As written, this proposed "patient-doctor agreement" imposes demands and rules only on physicians, and inevitably many people have condemned it as mere "hot air." Although it does sound filled with platitudes and is very ambitious, Andrew Huang and others like him not only believe that it can be applied in practice, they have begun to promote it in hospitals and through the education system.
We look forward to the day when the patient-doctor agreement will spread to all hospitals, when doctors can really keep their oaths constantly in mind. Perhaps in this age when health insurance, hospital administrators, high technology, and other "third parties" have come between patients and doctors, upholding the basic mutuality of the relationship between patient and doctor-between, at the most basic level, two human beings-we can help remedy the shortcomings in our medical system.
That will be the day when Taiwan can truly be considered a "medical utopia."
Questions for consideration
Do I need surgery?
Why do I need surgery?
What will happen if I don't get surgery?
Are any other treatment options available?
What kind of surgery do I need?
Which type of surgical procedure do I need? What are the possible complications?
Which type of anesthetic will I need? Does the hospital have a professional anesthetist available to oversee the whole procedure?
Who will do the operation? How skilled a surgeon is he/she?
After the surgery, what's next?
How long will it take for me to return to full health after the operation?
Do I have any more doubts or questions about the surgery?
(courtesy of the Taiwan Health Reform Foundation, compiled by Chang Chiung-fang)