Mariam Rahmani, MD

When a patient fails to improve with usual treatment, we begin a process of examining the causes of ineffectiveness: Is the medication dose too low? Is the patient’s body metabolizing the medication too quickly? Is the patient not following our directions? Is there a flaw in our understanding of the patient’s condition?

Health care in the United States is in poor health, its quality steadily declining since the 1960s. According to the World Economic Forum , in the 1950s the United States ranked first among the developed nations in the quality of health care. But now, despite enlisting renowned physicians, public health experts, economists, business leaders, and specialists in the treatment of ailing systems, we rank near the bottom.

What is the explanation? Is something being overlooked in the current effort to improve medical care? Do we not understand the cause of this fatal condition? The authors believe it is the importance of relationships that is being ignored; the physician-patient relationship, family relationships, and relationship systems in the community. Four key elements in our current health care system are responsible for this failure to acknowledge these critical relationships.

The foundation of the Industrial Revolution was the ability to create interchangeable parts. For example, workers on an assembly line build excellent automobiles cost-effectively. Health care administrators are using that model in medicine. The model of industrialized medicine works poorly when dealing with human beings, and is cost-effective only in the short run. Patients and practitioners are not interchangeable parts. Patients and their illnesses are too complex for a one-size-fits-all design. A health care model that does not recognize each patient as a unique person existing in a unique network of relationships–with medical practitioners, family, and community–results in increasingly poor outcomes, as the data demonstrate.

Systematic ignoring of the physician-patient and physician-family relationships

Treatment outcomes decline when patients see a different physician at each visit. The industrialized model excludes the importance of relatedness between physician and patient, losing the stabilizing relational linkages. For example, patients in hospitals cared for by their primary care physician are more likely to be discharged home and less likely to die within 30 days than those cared for by hospitalists who do not have an ongoing relationship with the patient and family.

The lack of sustained relationships between physicians and patients, and physicians and families, in the context of their community, impairs the effectiveness of treatment. It is costly to the physician’s sense that their work is meaningful, and thus costly to physician morale. Systems that fail to attend to the physician-patient relationship lead to decreased treatment effectiveness, physician burnout, early retirement, and increased rates of physician suicide.

Healing is more likely in the context of families than healing in isolation

Without attention to context, our words, actions, and experience have no meaning. Family and community relationships are the context of our patients’ lives. Strong social connections are associated with increased longevity. For example, marriage is a protective factor against cardiac disease and the death of a spouse is associated with increased rates of physical illness in the surviving spouse. For individuals with a chronic illness, treatment without consideration of family and community appears simpler and more efficient, but leads to sterile, out-of-context, uninformed treatment, blinding both the patient and the physician from seeing both the illness and the solution.

The undermining and erosion of family and community

Regulations and reimbursement systems that reduce the medical interaction to a specific procedure diminish the involvement of families and communities in a patient’s recovery. The Health Information Portability and Accountability Act (HIPAA), for example, which was established to protect patient confidentiality, immediately became an obstacle to communication with the people in the patient’s life who can help with follow-up appointments, medication adherence, continuity of care, and emotional support.

The 4 elements described point to both the fatal condition and its solution. Attention to the whole person, focusing on relationships with physicians and nurses, patients and families, and the web of community relationships available in every community to every patient, helps people get and stay healthy. Any potential solution to the health care system that ignores relationships will always be ineffective. If industrial medicine worked, and at this point we’ve done that experiment, costs would not be rising, patients and physicians would not be dissatisfied, and health would be improving.

is Adjunct Associate Professor, Geisel School of Medicine at Dartmouth, Hanover, NH.

is training director of Child and Adolescent Psychiatry at the University of Florida.

*Members of the Research Committee, Group for the Advancement of Psychiatry also include Dr John Beahrs, Emeritus Professor of Psychiatry, Oregon Health and Science University, Portland; Dr Allan Josephson, (Former) Professor and Chief, Division of Child and Adolescent Psychiatry, University of Louisville School of Medicine; Dr David Keith, Professor Emeritus, Department of Psychiatry and Behavioral Sciences, Upstate Medical Center, Syracuse, NY; Dr Patrick Malone (1944–2016); Dr Alan Swann, Professor of Psychiatry, Baylor College of Medicine, and staff psychiatrist, Houston VA Medical Center; Dr William Swift, Emeritus Clinical Professor of Psychiatry, University of Wisconsin School of Medicine and Public Health, Madison; Dr Johan Verhulst (1938–2019); and Dr Douglas Kramer, Emeritus Clinical Professor of Psychiatry, University of Wisconsin School of Medicine and Public Health, Madison, and Chair, GAP Research Committee.

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There are 4 crucial failings in our current health care system, where the importance of relationships is ignored.  

Mariam Rahmani, MD

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