Our healthcare system is broken and in dire need of reform. We all know the statistics: the US spends $2.7 trillion on healthcare, 30% of which is waste in the form of unnecessary tests and unnecessary treatments. Conflicts of interest are rampant, with 94% of doctors reporting an affiliation with a pharmaceutical or device manufacturing company, and many more insidious influences including salaries being tied to “productivity.” Dozens of studies have shown that these conflicts of interest have a real impact on care, and are a major driver of excessive cost and avoidable harm.
On my recent book tour, and inspired by the conference on Preventing Overdiagnosis, I discovered an even bigger problem than the cost of care. There is a rampant and growing epidemic that we seldom discuss—the epidemic of fear. It’s understandable why patients are scared when they come to us. They’re not feeling well. They’re scared of what might happen.
But there’s another layer of fear, one that begins and ends with trust. Patients no longer know if their doctors are prescribing a medication or recommending a treatment because it is best for them—or because the doctor gets paid more to do it. Even if doctors aren’t in fact influenced, the perception makes our patients wonder, and it makes them scared.
Traditionally, medicine has maintained a certain mystique. While there has always been information asymmetry, patients and doctors established longstanding relationships, and patients trusted that doctors had their best interests at heart. However, today’s medical landscape is very different. Few patients have longstanding relationships with their doctors. They have little to go on when deciding who to trust with their health, then are kept in the dark on matters ranging from cost of care to doctors’ motivations to necessity of tests and treatments.
In a time when they are already vulnerable and scared, patients have become even more afraid that they may not be receiving the right care for the right reasons. Doctors, too, have become afraid of their patients; much has been written about the fear of malpractice leading to hiding mistakes and practicing defensive medicine.
This mutual fear has led to distrust, disconnection, and poor medical care. The driver of fear is secrecy and shame, and the antidote is honesty and transparency. Doctors are public servants whose duty is to be accountable to our patients. We need to break through the barrier of fear by sharing with our patients and the public who we are.
This is why I’m starting a new campaign, “Who’s my doctor? The total transparency manifesto.” Participating doctors produce a voluntary, public disclosure statement that includes the following: revenue streams of all payments, salary contribution and how salary is determined (i.e. hourly, RVU system, incentive/bonus), paid and unpaid board membership, investments, volunteer activities, professional interests, hobbies, and philosophy of practice.
Doctors already disclose much of this information when they apply for jobs and when they submit to medical journals. So why shouldn’t this information also be available to the public? Our patients have a right to know what influences their doctors may have that affect their care. It holds doctors accountable to our patients while at the same time humanizing us and reinforcing our role as socially responsible public servants.
Many patients may well decide that this information is irrelevant and never look at it. However, it should be available in a public, easily searchable database for those who do think it matters. Patients then have the option of identifying a doctor whose philosophies match their own. They can also help to encourage their doctor to participate in this project.
Many doctors may have qualms about their information being available in such a public forum. However, in the era of Google and social media, much of this information can already be found online, and having a voluntary disclosure gives more control to the doctor. Also, experience with other transparency pilots such as Open Notes has demonstrated that openness leads to better communication, more trust, and better care, and it only follows that a more open relationship with our patients leads to less fear and less malpractice.
I believe that this form of radical transparency is paradigm changing. It is changing the culture of medicine from one of secrecy and mystery to one that is totally open to patients. It is a public demonstration that patient interests are primary, that reaffirms the reasons why each of us went into medicine. Every time I tell my patients about my decision to be a totally transparent doctor, every time I share my Total Transparency Manifesto, I am saying, I’m your doctor. I’m looking out for you. I’m free of influence that could affect you. Don’t be afraid of me; trust me. I’ll be vulnerable with you.
Over the last few weeks, I’ve been discussing this idea with my colleagues and my patients. So far, I have myself and 10 other doctors who are willing to be totally transparent doctors. I’d love to have doctors of all specialties to participate, to say, I’m doing what I can to restore professionalism and break down the barrier of fear.
Doctors of all specialties, in the US and around the world—I’d love to have you join us. What you need to do is to write to me. Then, commit to is to write a Total Transparency Manifesto for the website (full website TBA; see more information and my manifesto disclosure on my webpage), tell your patients about it, and share your experience with me and the readers on my blog.
And patients—what do you think? Please post your responses. Over the next few months, I’ll be writing more about my own experiences as well as the experiences of my fellow transparent doctors and our patients. Please join us in this mission to counter fear and restore trust.
Leana Wen, is an attending emergency physician and director of patient centered care research at George Washington University. She is the author of When Doctors Don’t Listen: How to Avoid Misdiagnoses and Unnecessary Tests, and serves on the advisory council of Lown Institute’s Right Care Alliance. For more information, visit her blog The Doctor is Listening or her website. Follow @DrLeanaWen.
Competing interests: The author has completed the ICMJE uniform disclosure form at www.icmje.org/coi_disclosure.pdf and declare: no support from any organisation for the submitted work; she is an unpaid consultant to the Lown Institute, Patient-Centered Outcomes Research Institute, and Medical Education Futures Project; no other relationships or activities that could appear to have influenced the submitted work.”