Neal Chan
Boston, Massachusetts, United States

Pulling up a chair

On my fourth year Cardiology rotation, I cared for an elderly patient with atrial fibrillation and worsening heart failure. On rounds, a plan was made to attempt cardioversion and pursue rhythm control of his atrial fibrillation with amiodarone. As we entered the room, we found a nervous family gathered around the patient, made more nervous by the appearance of a whole group of doctors. My attending sat down next to the patient, and they started talking, not about his atrial fibrillation or heart failure, but about their grandkids and hometowns. Only after the patient felt more at ease did my attending ask him, “What is your understanding of your heart disease?” When it came to discussing his goals and wants, his answer was already clear: he wanted to feel well enough to go fishing and spend time with his grandkids, but worried about the financial costs of his care and finding transportation to his appointments.

The crucial action my attending took that day was to draw up a chair next to the patient and get to know him. This made it clear to the patient that this doctor cared enough to take the time to fully understand him. In some ways it recalled an era when the medical system consisted of only the doctor, his patient, and the trust between the two. Physicians of the past devoted time to build this trust.

This personal approach to the patient-physician relationship was most palpable in primary care. In early American hospitals, family physicians also continued to attend to their hospitalized outpatients. As a result, the physician was valued for his tenderness and human touch as much as his clinical expertise. Psychiatrist Carl Binger, reflecting in 1956 on this earlier era, described the family doctor’s all-encompassing role:

Time was, and not so long ago, when the family doctor delivered babies and supervised their nursing, their weaning and their teething, when he vaccinated them and saw them through their measles and chicken pox and whooping cough. He told the boy about the facts of life and treated the girl for her menstrual cramps. He advised about diet and rest, gave spring tonics, clipped tonsils, set a broken arm, reassured father who couldn’t sleep because of business worries, pulled mother through a case of typhoid or double pneumonia, reprimanded the cook who was found, on her day out, to have a dozen empty whisky bottles in her clothes closet, gave advice about the young man’s choice of college and profession, comforted grandma, who was losing her memory and becoming more and more irritable, and closed grandpa’s eyes in his final sleep. He went on his endless, mysterious, and incessant rounds leaving in his wake a faint odor of carbolic with which he disinfected his beard.¹

The concept of a personal doctor once figured prominently in America’s consciousness, but later fell away in favor of tighter, more efficient physician schedules. In his 1985 book Bedside Manners: The Troubled History of Doctors and Patients, historian Edward Shorter described this clear evolution in the patient-physician relationship. He described an old-time doctor who saw seven patients in 3 hours, patiently listening to each complaint. When he asked the doctor, “How do you make any money?”, the doctor shrugged and responded, “I’m not all that interested in making money.”² Shorter later watched another doctor see a patient depressed after a heart attack. The physician asked his patient, “In your own mind, is this something you expect to get better?”, then, “What can we do to help you?”, and finally listened attentively and unhurriedly as she explained how insensitive her ex-husband had been after her heart attack. He concluded the visit by giving her a hug. Shorter reflects that these two physicians’ approach predates hurried and impersonal postmodern medicine. They had the autonomy and time to make conversation with their patients and provide essential psychological support—thus treating the patient rather than the disease.²

More recently, medicine has seen unfathomable leaps in scientific progress. Hospitals, which once served as places to tend to patients as disease took its natural course, became centers of effective treatment. At the same time, medicine has transformed into a business that not just rewards but demands efficiency and volume. In his book Anatomy of an Illness, writer Norman Cousins, reflecting on his own struggle with chronic illness, wrote that:

Time is the one thing that patients need most from their doctors—time to be heard, time to have things explained, time to be reassured, time to be introduced by the doctor personally to specialists or other attendants whose very existence seems to reflect something new and threatening. Yet the one thing that too many doctors find most difficult to command or manage is time.⁴

The future of the patient-physician relationship

In the 1980s, Roy Porter lamented, “medicine has now turned into the proverbial Leviathan, comparable to the military machine or the civil service, and is in many cases no less business- and money-oriented than the great oligopolistic corporations.”¹ Since then, there has been rising concern about the dominance of large multi-hospital healthcare systems, the waning viability of private practices, and the resultant growth of for-profit healthcare. Falling Medicare payments and skyrocketing overhead costs are causing strain on hospital budgets and private practices, forcing the consolidation of independent hospitals and physician-owned practices under large conglomerate hospital systems, insurers, and private equity firms.⁵ According to the American Medical Association, in 2024, 42.2% of physicians worked in physician-owned practices, an 18% decrease from 2012. The percentage of hospitals owned by companies controlling three or more hospitals increased from 11.6% in the 1980s to 56.1% in 2025.⁶ As a result, hospitals and outpatient clinics alike are incentivized to create a system that is efficient and lucrative, and patients are noticing.⁷

Fee-for-service systems reward clinicians’ volume of patients and procedures, incentivizing employers to enforce short, frequent clinic visits, presumably to maximize revenue with the side effect of creating over-utilized, low-value care.⁸ Norman Cousins quoted Dr. Grey Dimond, the provost of the School of Medicine of the University of Missouri at Kansas City, who wrote, “When the physician placed himself on a fee schedule wherein he could justify his livelihood only by ‘doing something,’ he inevitably began shutting down the essence of a physician’s purpose: the human contact.”⁴ As the for-profit corporate medicine continues to push for “doing something,” the integrity of the patient-physician relationship may become jeopardized. Financial incentives, layered onto the healthcare system over decades, now lurk in the room with the physician and patient.

Despite external forces, individual clinicians can take steps to preserve trusting patient-physician relationships within his or her practice. Patients highly value physicians who actively listen and even perceive them as being more knowledgeable.⁹ Even in a healthcare system of large corporations and economies of scale, the essence of healing may still rest in something as simple as sitting down and listening.

References

1. Porter R. The Greatest Benefit to Mankind, A Medical History of Humanity. WW Norton & Company; 1997.
2. Shorter E. Bedside Manners: The Troubled History of Doctors and Patients. Simon and Schuster; 1985.
3. Fred HL. The late forties and early fifties: a memorable time in medicine. Tex Heart Inst J. 2013;40(5):508–9.
4. Cousins N. Anatomy of an Illness as Perceived by the Patient. WW Norton & Company; 1979.
5. More physicians move to practices owned by hospitals & private equity groups. 2025. Accessed 8/21/2025. https://www.ama-assn.org/press-center/ama-press-releases/more-physicians-move-practices-owned-hospitals-private-equity
6. Fuse Brown EC. Defining Health Care “Corporatization”. N Engl J Med. Jul 3 2025;393(1):1–3. doi:10.1056/NEJMp2415485
7. Bhatla A, Bartlett VL, Liu M, Zheng Z, Wadhera RK. Changes in Patient Care Experience After Private Equity Acquisition of US Hospitals. Jama. Feb 11 2025;333(6):490–497. doi:10.1001/jama.2024.23450
8. Singh Y, Song Z, Polsky D, Bruch JD, Zhu JM. Association of Private Equity Acquisition of Physician Practices With Changes in Health Care Spending and Utilization. JAMA Health Forum. 2022;3(9):e222886–e222886. doi:10.1001/jamahealthforum.2022.2886
9. Schnelle C, Jones MA. Characteristics of exceptionally good Doctors-A survey of public adults. Heliyon. Feb 2023;9(2):e13115. doi:10.1016/j.heliyon.2023.e13115