I have noticed an important trend in many social media posts. Increasingly, there is a tendency to define everything as a transactional relationship. Here, I am defining a transactional relationship as one where the relationship is conditional upon the exchange of desired benefits. I will give you this, and you will give me that. It is not about building a connection or sharing a worldview. It is about a beginning, a middle and an end, rather than having an open-ended outcome. It is certainly present in many political posts but certainly is appearing in posts about potential romantic partners, and in more basic posts about friends and friendships. It can be positive and future-focused, like “these are the traits I want in a parter” or “I am voting for Candidate X because I want them to do this one thing.” It can also be retrospective and often negative, like in the millions of FAFO1 posts. Even in the comments section to the crazy or delusional rants, responses may attempt to be helpful but usually come off as smug or dripping with schadenfreude.2 The issue for me, though, is that this approach to communication is bleeding into the real world and it is not generally making things better.
Now, you might be confused, as this website is focused on all things patient experience. But this social media trend has gotten me thinking about how this turn in interpersonal relationships has changed the consumer space generally and healthcare specifically. While it seems like a trip to the doctor would be the archetypal transactional relationship (I am sick, make me better), both patients and providers will complain when that is actually at the center of the encounter.
Patients will complain about the fact that everything must happen in an appointment. Any question asked is answered with ‘make an appointment.’ Some will see this answer as less about solutions and more about money. This creates fertile soil, then, for people to run to Dr. Google or chase alternative solutions online. Meanwhile, doctors will complain about the fact that patients don’t want to take ownership of their issues and are looking for a quick fix. They will be resistant to medicine when it is a vaccine, but more than willing to ignore side-effects when it is a GLP-1. This leads providers to also stereotype patients as always looking for the easy button that requires less personal agency. The outcome is that this rather simplistic approach to engaging in healthcare has both made clinicians more stressed and patients sicker. There are three broad reasons why this form of communication and interaction does not serve healthcare very well.
Self-Centered vs Collaborative
Transactional relationships put a high premium on quid pro quo with a decidedly self-centered perspective. While this may seem aligned with the broad call for “patient-centered care,” it is not. There certainly is a need to bring the patient to the center of the care discussion, but the phrase also implies that patients will take direction, advice and feedback from the care team as well. While the patient is the one receiving the care, the process is a two-way street.
This may seem odd to call out in healthcare, since the patient has a problem that led them to seek care, so we may forgive them a certain amount of self-centeredness. But I am not referring to moments of life-or-death where I will care more about MY heart attack and less about how your day is going. I am talking about how patients will sometimes have a preconceived notion of what is wrong and demand a specific response and then get irritated when you don’t simply comply. I am not talking about drug-seekers, but I am talking about people who demonstrate drug-seeking behavior. Parents who demand antibiotics for their child with a virus. Patients who will demand an MRI or other test, regardless of whether it is warranted. On the other side, patients who argue against a throat swab, lab test or MRI as being pointless based upon what WebMD said. Or they get defensive when asked if they have their vaccines current or are actively managing their high blood pressure.
Now it isn’t just patients who behave in a self-centered way. We have all met doctors who get annoyed when their diagnosis gets questioned or are put out because they are asked to address something that the patient saw online. I have heard nurses yell, “You are not my only patient!” and have heard some comment about how they like to work overnights because they don’t have to deal with demanding patients and families. Some people are just better with bags.3
Both miss the fact that, for the best possible outcome, there must be more focus on collaboration. To solve the problem in the moment, there must be open minds and no egos. Once the problem has been resolved, there must be clear communication to prevent it from happening again. Dismissing the other, or only accepting what they offer AFTER you get what you want, will definitely lead to more heat than light.
Immediate vs Aspirational
Another element of the transactional relationship that does not translate well into healthcare is the implication (or explicit statement) that the transaction needs to be immediate and complete. When someone’s dating requirements are six feet tall, six-pack abs, and a six-figure income, these are presented as Day-One requirements and there is no wiggle room. As these are presented as past accomplishments, clearly there is nothing aspirational about them.
Meanwhile there is little in healthcare that is immediate and complete. Even interventions that are immediate, like the birth of a baby or a coronary artery bypass graft (CABG), have significant post-operative needs and education, meaning that the procedure itself does not complete the care. In some cases, like cardiac blues or post-partum depression, these needs are more emotional, can linger and be difficult to spot.
Further, a lot of healthcare focuses on aspirational goals rather than complete resolution. While zero pain is certainly an aspirational goal for pain management, it is rarely going to be the long-term actual outcome. The same goes for weight loss, cholesterol management, diabetes management and a host of other chronic problems. Continued success is predicated upon continued effort. And that success will never be defined as perfection but instead defined as best-possible.
Assumption of Equality vs Power Dynamic
Whether acknowledged or not, the transactional relationship assumes some level of equality, where you can deliver on my wants and I can deliver on your wants.4 This can explain some care experiences, like when a patient can shop around for a primary care doctor who fits their needs or schedule better than others. Mostly, though, patients don’t have much power. In the short term, the patient’s needs, be it medication refills or major surgery, are not a preference, but a must-have. In the mid-term, that physician is a gate-keeper to possible interventions or referrals to a specialist. A patient can ask or demand, but it will still be filtered through a doctor’s willingness to act. Even the nuclear option, where a patient can fire their doctor, is a heavier burden on the patient than the doctor, since the doctor will have an easier time filling an appointment slot than a patient will have getting another doctor. Plus, this power is balanced against a doctor’s ability to fire the patient. In both situations, the person who is disadvantaged in the firing is the patient.
While this can lead to passive-aggressive or petulant behavior in patients, the failure to appreciate this power dynamic by clinical staff is the bigger problem. Clinicians may understand that they have the power here since they have the knowledge and expertise, but they often seem unaware that with this power comes responsibility. I have often heard clinicians complain that a patient’s behavior was not aligned with their needs. Patients won’t take their diabetes seriously until the threat or reality of amputation looms. They won’t take the ‘little steps’ like dieting and exercising seriously to manage their high blood pressure.
I have always found these comments to be patronizing and annoying. The rational mind may certainly process these things logically, but that is not how humans often respond. We often react emotionally. We may be a care team, but I am the one with cancer. I was present when a loved one was diagnosed with multiple sclerosis and again when the second opinion reinforced the diagnosis. I was startled that neither neurologist knew how to handle the tears. Heck, neither even had tissues in their office.5 You have the power; we do not. You tell us we are going to die; we get to give you a one-star review on Google. We are not equal in this interaction. The least you can do is be honest in this reality and own that responsibility.
In the end, the one thing that this transactional approach does to damage the healthcare encounter is its inability to accept open-ended relationships. Articulated or not, transactions have a beginning, a middle and an end. Once the bill is paid, my relationship with the waitstaff in a restaurant is over. Even when I go back to a restaurant repeatedly, there isn’t often a recognition or appreciation of an ongoing relationship. There have been times when I got to know a restaurant owner and we would greet each other and ask about the other’s day. But these moments are rare and indicate a relationship that has crossed from simple transaction and into something else. Perhaps not a full-fledged friendship but at least some joy and appreciation for what the other brings to the table and is not captured in the bill for service. I have never invited my primary care doctor home for dinner, but it is only when that relationship crosses over into something that beyond cause and effect, problem and cure, that I feel like I have been heard and healed.
1FAFO stands for Fuck Around and Find Out (or Fool Around and Find Out, if your mom asks you want it means) and essentially it means that if you dance with the bear, you are going to get mauled.
2Technically, schadenfreude is a German word meaning deriving pleasure at someone else’s misfortune. This is mostly deriving pleasure at someone else’s delusions. If anyone knows the German word for that, please post it in the comments.
3My friend Hope Brown was telling a Disney story in a presentation once, about how their process where guests coming to Orlando can have their bags picked up and taken to the hotel, thereby allowing the guest to skip baggage claim and move straight to having fun. This also allowed Disney to be more efficient in running shuttles from the airport to the hotel, better utilizing space and effort. She further pointed out that this was more efficient with personnel as “some people are better with people and some people are better with bags.” This got a laugh and subsequently became a shorthand for the service skills of some people.
4The phrase “acknowledged or not” is important, since those with a long list of demands may find the list of reciprocal demands to be surprising and daunting. A friend of mine’s dad is an accountant. He would never turn down a client who has been difficult in the past. He would just quote them a figure that would (a) have them turn him down, or (b) make dealing with the client’s demands palatable and profitable.
5This person’s journey taught me a lot about patient experience, but also about how humans process math and outcomes. I will tell this story in a future essay.
PX Matters with Joseph Snipp 
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