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\title{This is Not What I Want, Doctor}
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             \author[1]{Keerti  Saxena}

             \affil[1]{  University of Phoenix}

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\date{\small \em Received: 12 December 2018 Accepted: 3 January 2019 Published: 15 January 2019}

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\begin{abstract}
        


A qualitative transcendental phenomenological study was conducted to explore the lived experiences of the physicians who may perceive their professional integrity challenged by and in conflict with patient autonomy and patient consumerism. A sample of fifteen physicians was drawn from a population of physicians practicing medicine in the central Tennessee area for the last 5 years or more. Open ended one-on-one interview questions revealed a rich data on personal lived experience that was analyzed using Modified van Kaam approach by Moustakas. A subjective interpretation of the data identified an emergence of five main themes. Those themes were (1) autonomy of patients must be acknowledged, (2) consumeristic behavior of patients in healthcare market was increasing, (3) physicians? roles are evolving in response to demands of consumerist patients, (4) physicians expressed dissatisfaction with burdens associated with evolving roles, and (5) increased burdens have created conflicts in physician-patient relationship. 

\end{abstract}


\keywords{revolutionized healthcare delivery, patient autonomy, patient consumerism, professional integrity, participatory relationship.}

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\let\tabcellsep& 	 	 		 
\section[{Introduction}]{Introduction}\par
he physician-patient relationship is the foundation of the medical practice of healing and at the core of medical ethics \hyperref[b13]{(13,}\hyperref[b35]{32)}. In the past few decades, this relationship has evolved from the paternalistic physicians and silent patients of Hippocratic era to the empowered and autonomous patients of the current era \hyperref[b35]{(32)}. Numerous factors have contributed to the evolution of physician-patient relationship and in reshaping the quality and structure of healthcare delivery. Healthcare is rapidly being transformed by new medical technologies and empowered, computer-informed patients \hyperref[b4]{(5,}\hyperref[b32]{29)}. The information that physicians gather during treatment of their patients and the treatment decisions they make are no longer theirs. The information is protected health information (PHI). The legislative healthcare reforms have also contributed to revolutionizing healthcare and redefining physician-patient relationships \hyperref[b21]{(21)}. Information technology, comprising of an array of medical equipment and mass media, has become the tool of revolutionized healthcare delivery of the 21 st century \hyperref[b38]{(35)}. The healthcare revolution is transforming the physician-patient relationship from the classic physician paternalism model to the modern patient autonomy model, one in which the patients are increasingly taking ownership of their health and healthrelated decision making \hyperref[b4]{(5)}. Patient consumerism and patient autonomy are now new dimensions to the physician-patient relationship and together, a force to be reckoned with. 
\section[{II. A Research Study -Purpose, Problem, and Method}]{II. A Research Study -Purpose, Problem, and Method}\par
The purpose of the qualitative transcendental phenomenological study was to explore the lived experiences of the physicians who may perceive their professional integrity challenged by and in conflict with patient autonomy and patient consumerism. In this qualitative phenomenological study, the lived experiences were elicited through in-depth, face-to-face interviews. A phenomenological design was appropriate for the research study because it provides a rich and meaningful description of lived experience in a balanced way \hyperref[b27]{(25)}. The phenomenological design of the research study embodied rich descriptions of lived experiences of a phenomenon \hyperref[b11]{(11)}. The use of phenomenological design ensured focus on the wholeness of the experience and permitted the sharing of subjective perception of the phenomenon experienced by the physician. Knowledge gained through transcendental approach has the potential to contribute to resolution of problems and overall productivity (4). In the qualitative research study, transcendental phenomenological method was beneficial in uncovering the deeper meaning and understanding of the challenges by, and conflicts with, patient autonomy and patient consumerism and perhaps found a resolution of participatory relationship between the physicians and patients.\par
The general problem addressed in this qualitative study was the impact of increased patient autonomy and patient consumerism on healthcare delivery. The specific problem addressed in this qualitative phenomenological study was the conflicts and challenges posed to the physicians' professional integrity due to increased patient autonomy and patient consumerism.\par
A sample of 15 physicians was drawn from a population of physicians practicing medicine in the central Tennessee area for the last 5 years or more (from the date of research study). Two open-ended research questions and 10 interview questions revealed rich data on the personal-lived experiences of the physicians residing and practicing in the central Tennessee area. 
\section[{III. "I want This and not That, Doctor!"-Patient Consumerism}]{III. "I want This and not That, Doctor!"-Patient Consumerism}\par
The provider-patient relationship is a privileged one but also a complex one \hyperref[b5]{(6)}. Several factors have influenced the dynamics of physician-patient relationships and the way physicians deliver healthcare services. One such important factor was patient consumerism. A consumerist patient seeks sources other than the physicians to acquire medical information and rely heavily on such information \hyperref[b9]{(9)}. Patient consumerism is on the rise. Internet has quickly become the alternative and most popular source of healthcare information. There is a vast amount of healthcare information available through Internet. Web-sites like WebMD (2014) and Health line (2014) instantly provide vast information on the diseases, diagnosis, medical explanations, and possible treatments. According to the statistics released by The Pew Research Center, approximately 59\% of the American adults have retrieved health information online, 35\% have looked online for specific medical conditions, approximately 33\% of cell phone owners have used their cell phones to access health information, and 19\% of smart-phone owners have downloaded health applications \hyperref[b12]{(12)}. The easily accessible information on the Internet has increased people's knowledge, a sense of ownership of one's health, and the awareness of patient's rights and autonomy.\par
Another factor influencing physician-patient relationship was the advertising and marketing of healthcare services directly to the patients. The healthcare technology has transformed patients into healthcare consumers, who in turn influence the services provided in the market \hyperref[b28]{(26)}. Patients are considered consumers and healthcare services are considered a product. Patients are the main target population in the marketing and advertising of healthcare services and products. Medical Direct-to-Consumer advertising or DTC advertising has affected the physician-patient relationship \hyperref[b10]{(10)}. Purchasing many of advertised healthcare products require a physician's approval and prescription first, but that has not deterred the advertising trend of these medical and healthcare products. Some of the surveyed physicians reported that they are pressured by the patients to prescribe the DTC medications. The physicians expressed concerns that the drug companies advertise various benefits of such DTC medications without context, while not fully disclosing the risks and side-effects.\par
Patients are using the newly acquired knowledge based on multiple web-based sources and television advertisements to customize their care. Armed with such knowledge, many patients walk into their doctors' offices with their own 'lists' of 'wants' and 'don't wants'. They are very specific about requesting certain medications and/or procedures and rejecting certain medications and/or treatment plans. All they appear to be looking for is a validation of their requests in the form of a certified physician's signature.\par
IV. "This is not What I want, Doctor!" -Patient Anatomy\par
The revolutionized healthcare delivery has the possibility of unintended adverse impacts on physicianpatient relationships, while creating political, social, and ethical challenges \hyperref[b33]{(30,}\hyperref[b34]{31)}. Enforcement of HIPAA laws and the new Patient's Bill of Rights resulted in an increased awareness of patients' rights and ownership of one's health. Patients are considered autonomous individuals with the right to seek, alter, and reject medical treatments. New medical technologies, Internet access, and multiple health-related websites on the Internet are newer venues, apart from the physicians, to obtain information about health. Internet access has become a cornucopia of medical information.\par
However, the responding physicians pointed out that if the information on the Internet is inaccurate, irrelevant, and misinterpreted, then Internet-acquired information often leads to inappropriate requests by patients for clinical interventions, challenging physicians' authority, miscommunication, and damaging to physician-patient relationship \hyperref[b23]{(22)}. Increased patient autonomy and patient consumerism have led to discordant expectations between physicians and patients (3). Patients often exercise autonomy and consumerism to reject treatments prescribed by their physicians or to demand treatments that may be against medical advice. The refusal of or demand for treatments leads to discordant expectations. Discordant expectations create uncertainties regarding the physicians' roles and authorities \hyperref[b2]{(3)}. They also lead to a loss of trust by the patients in their physicians' beneficence and their clinical judgments. 
\section[{V. The Physician-Patient Conflicts}]{V. The Physician-Patient Conflicts}\par
In the early 1900s, physicians established themselves as the ultimate and knowledgeable healthcare professionals who knew what was best for their patients \hyperref[b14]{(14)}. In the process, patients were categorized as the ailing and the vulnerable population who sought the physician's expert advice to become better. The unquestionable authority of the physicians and the dependence of the patients on such authority led to an accepted paternalistic approach to medical care. Within this approach, the physician was in control while the patient was under the control.\par
From the Hippocratic era of physicians' paternalism to the Affordable Health Care Reforms era of patient autonomy, the physician-patient relationships have evolved drastically, as the decision-making has shifted from the paternalistic physician to the autonomous patient \hyperref[b35]{(32)}. After conducting an extensive literature review, a gap emerged on the subject of understanding the evolving of patient-physician relationship in context to the newer era of healthcare. It pointed to the challenges physicians face relative to their professional integrity and obligations resulting from increasing patient autonomy and patient consumerism.\par
Internet based information and direct-to-patient advertising are the new cultural and social forces that perceive the patients as the consumers of healthcare products and services. The consumerist patients are obtaining clinical knowledge through media and Internet sources, outside direct consultations with their physicians \hyperref[b1]{(2)}. Empowered by the exclusive attention by advertisers and new-found knowledge through the Internet and television, it appears that patients are more willing to challenge their physicians' clinical authority.\par
A tension is created between a patient's autonomy and a physician's clinical duties, when a patient is in disagreement with the physician's plan of care. According to Lantos, Matlock, and Wendler (2011), this tension poses the dilemma of how the physicians should approach cases in which their own medical integrity is challenged by and in conflict with the need to respect a patient's autonomy (p. 495). Patient consumerism and patient autonomy, when misinformed and misdirected, often lead to physician-patient conflicts.\par
Increasing patient autonomy and patient consumerism appeared to pose increasing challenges to physicians' professional integrity. A physician-patient consultation could turn into a conflict due to lack of information, lack of support, perception of indecisiveness, and challenge to personal values \hyperref[b20]{(20)}. When the consumerist patient demands customized health care that a physician believes is not conducive to good health care, a conflict arises between the patient's autonomy and physician's clinical decision making. Dealing with conflicts with patient autonomy is a challenge to a physician's own integrity, which in turn evokes anger and frustration among physicians \hyperref[b15]{(15)}. Conflicts in a physician-patient relationship lead to ineffective medical outcomes. Conflicts compromise the clinical integrity as well as the health care outcome.\par
Entwistle, Carter, Cribb, and McCaffery (2010) emphasized the value of patient autonomy but raised questions regarding its overemphasis. \hyperref[b8]{Entwistle et al. (2010)} contended that the autonomy of patients should be respected as an important aspect of biomedical ethics. However, respecting patient autonomy does not mean that the patients should dictate their health care while the physicians stand by and honor the patients' wishes. It also does not imply that physicians should not discuss or question a patient's choices, while allowing the patients to take any course of action related to healthcare. It also creates a less than optimal medical outcome that negates the purpose of consulting an expert physician. The acceptance of reduced professional responsibility or an uninvolved physician is even worse. A dire need to set certain boundaries to the usage of autonomy is necessary to avoid abuse of individual responsibilities \hyperref[b16]{(16)}.\par
Preventable medical errors were another manifestation of outcomes that create conflicts. According to a study done by the Institute of Medicine, preventable medical errors are responsible for more than 98,000 deaths per year, incurring healthcare expenses of approximately \$29 billion (1). Clash of interests or power struggle between the patients exercising their autonomy and physicians striving for optimal outcomes created negativity and deviation from the goal of superior patient care. These disagreements cause poor judgments that lead to harmful, yet preventable, medical errors.\par
The physicians also have an ever-present fear of lawsuits \hyperref[b36]{(33)}. The fear of lawsuits from the patients provokes the physicians to trust their patients less and practice defensive medicine. Simultaneously, the suspicions of being over-tested by the physicians makes the patients trust their doctors less. A lack of mutual trust mars the relationship between patients and physicians leading to malpractice litigations. The tedious, expensive, and slow litigation process can be emotionally draining and damaging to the reputation of the physicians (7). 
\section[{VI. The Committed Physician}]{VI. The Committed Physician}\par
A deeper analysis of the responses to the oneon-one interview questions of the research study led to an unexpected outcome of the research findings. The unexpected outcome was that the physicians believed that there are no apparent direct conflicts between the physicians' professional integrity and patient autonomy. On the contrary, the physicians welcomed their evolving roles as an educator, a guide, a counselor, a coach, and a partner. Another frequently emerging sentiment of the interviewed doctors was that they viewed themselves as an advocate to their autonomous and information-seeking patients. All participating physicians used these terms at one point or the other, seeming to take pride and enjoying being a guiding counselor while imparting their own valuable knowledge. Additionally, all participating physicians referred to the patients as 'my patients' rather than 'those patients', at one point or the other during the interviews.\par
The conflicts arose when the physician beneficence or the desire to do good was mired in some of the external factors. Those external factors were a) Controlling, time-consuming, and costly mandates by the government and insurance companies, b) Lack of proper resources and sufficient compensations to implement such mandates, c) Lack of control in the physicians' decision-making authority, d) Misguided concepts of patient autonomy and patient consumerism, and e) A lack of support from some of the medical organizations.\par
These findings indicated a sense of dissatisfaction among the participating physicians towards their changing responsibilities. The physicians are feeling burned out by the imposing and controlling factors that have seeped into the direct physicianpatient relationship. They are frustrated by the diminishing control over their medical decision-making. They are also feeling excessively burdened by the increasing time-consuming mandates with no backup of proper resources and compensations.\par
However, in spite of the frustrations, the physicians continued to strongly believe in the sanctity of physician-patient relationship and their profession. They felt that their medical knowledge and long years of training gave them a unique opportunity to contribute to their patients' quality of life. The participating physicians viewed themselves as the advocates and partners of their patients, more so, during the evolving healthcare environment. 
\section[{VII. Significance of the Study}]{VII. Significance of the Study}\par
The significance of this phenomenological transcendental study was that the study's results contributed to a better understanding of the underlying reasons of conflicts between the physicians' professional integrity and patient autonomy in context to patient consumerism. Exploring the underlying problems helped physicians ascertain the impact of conflicts and thus make better decisions \hyperref[b29]{(27)}. By understanding the reasons for conflicts, efforts can be made to strategically overcome those reasons and establish a positive and participatory relationship between physicians and patients.\par
Another related significance of this qualitative study was that the results may contribute to assuring effective, efficient, equitable, and timely delivery of healthcare, even as new healthcare reforms are rapidly changing the roles of physicians and patients. In order to meet the demands of changing roles, there is a need to move away from the old model of physician paternalism to patient-centered care and partnership \hyperref[b18]{(18)}. The transformation of physician-patient relationship to partnership and team-care may facilitate the mitigation of potential litigations and promote patient and physician satisfactions.\par
An important significance of the research study was to encourage leadership among the physicians. Their clinical judgment, their clinical and empirical knowledge, and their clinical skills are valuable in contributing to meeting or exceeding the standards of patient care. Practitioners must take the lead in risk management and safety delivery. To be leaders in healthcare organizations, licensed healthcare practitioners must possess the qualities of integrity, compassion, courage, and emotional maturity \hyperref[b30]{(28)}. The significance of the healthcare leadership lies in facilitating the establishment of a participatory professional relationship between patients and their physicians to promote a better overall health outcomes and functionality \hyperref[b17]{(17,}\hyperref[b26]{24)}.\par
The findings may expand the emphasis from the broader issue of general conflicts in physicianpatient relationship to the focused issue of physician dissatisfaction due to controlling and interfering external factors that may be contributing to the physician-patient conflicts. Contribution to the knowledge may result in reevaluating the physician-patient relationship in the era of empowered patients and healthcare reforms, thereby finding more appropriate ways to improve physician satisfaction.\par
The study will also be significant to the stakeholders of the healthcare system, who may use the findings for making decisions regarding efficient healthcare delivery. Some of the crucial stakeholders of the healthcare system are the physicians and their staff, the patients, the hospitals and their administrators, the government, the policymakers, the pharmaceutical companies, the insurance companies, the medical organizations, the medical suppliers, and the healthcare leaders. 
\section[{VIII. Concluding Discussion}]{VIII. Concluding Discussion}\par
In this research study, an attempt was made to examine how the physicians perceive the autonomy of patients as a challenge to clinical decision-making process. The goal of the study goal was to uncover deeper meaning and understanding of the challenges by, and conflicts with, patient autonomy and consumerism, as perceived by the participating physicians. The immediate revelation of the study was that the physicians are feeling burdened, frustrated, and burned out. The surprising revelation of this study was that they do not blame the consumerist and autonomous patients who are demanding customized patient-care. The surveyed physicians expressed confidence in customizing their healthcare delivery, while maintaining the highest professional integrity of a physician. They had confidence in their knowledge, training, experience, and above all, their rapport with their patients. They took pride in being the advocate and counselor to their patients in the trying times of rapidly evolving healthcare landscape.\par
Collectively, the surveyed physicians voiced an immense dissatisfaction with the controlling, timeconsuming, costly and often unnecessary mandates by the government and insurance companies. Compounded with the lack of proper support and adequate resources, and sufficient compensations to implement the mandates, the evolving healthcare era had inadvertently led to the loss of control in the qualified physicians' decision-making authority and dissatisfaction.\par
To overcome some of the dissatisfactions, a physician may opt to becoming a hospital employee. Hospitals are aggressively seeking physicians to hire them as employees for the hospitals' motives of gaining market share and increasing patient volume \hyperref[b25]{(23)}. Becoming a hospital-employed physician may not resolve the crucial concerns of the physicians regarding the loss of their professional decision-making authority. It may only serve to eliminate the burdens of practicing private medicine with the increasing operating costs and increasing responsibilities. A certain amount of physician-satisfaction may be derived by shifting such burdens to the hospitals, in exchange for a stabilized salary, stabilized work-hours, and a work-life balance.\par
If they choose to remain self-employed, physicians may opt to practice concierge medicine. Under the concierge medicine or direct-pay model, the physicians eliminate insurance billings altogether and collect a flat fee for their services, directly from the patients \hyperref[b37]{(34)}. Eliminating insurance billing facilitates returning of the clinical decision-making authority to the physicians, customizing their fee according to the paying abilities of their patients, and freeing the physicians from the obligations of several intrusive and unnecessary insurance mandates. As noted by \hyperref[b37]{Weiczner (2013)}, there are more than 5,500 concierge medical practices in nation, reporting that concierge model has enabled them to reduce overhead costs by 40\%, while reducing patient-fee. It is anticipated that under an established standard of accountability and transparency, the concierge medicine model will provide the physicians the satisfaction of providing quality care to the best of their abilities, without impinging upon their professional integrity. The physicians practicing concierge medicine may overcome their collective frustrations over the issues of loss of authority, timeconstraints, burdens of mandates, and reimbursementreductions. The professional satisfaction may lead to physicians perceiving patient autonomy and patient consumerism as participatory and not adversary outcomes of the healthcare reforms.\par
The research findings have contributed to the body of knowledge by drawing attention to the mandatory healthcare reforms that failed to take into consideration some of the adverse impacts on the physicians, the patients, and the healthcare industry. The physicians' job satisfaction and a participatory physician-patient relationship are essential in enhancing the quality of patient care. It is anticipated that the subjects, the organizations, and the society will benefit from the enhanced physician-patient relationships that may lead to mitigating risks, lowering healthcare costs, and improving the overall quality of the healthcare delivery.			\footnote{( )K © 2019 Global Journals This is Not What I Want, Doctor} 		 		\backmatter   			 
\subsection[{Acknowledgements}]{Acknowledgements}\par
This article is a reduction of an original published dissertation, "Conflicts between Physicians' Integrity and Patient Autonomy: A Phenomenological Study". It was authored by Keerti Saxena and chaired by Patricia D'Urso, Ph.D. The dissertation was successfully completed in December 2015. The dissertation would not have been possible without the extremely valuable and honest input of the participating physicians. Likewise, this resulting manuscript would not have been possible without encouragement and participation of Dr. D'Urso. 			  			 
\subsection[{Conflict of interest statement}]{Conflict of interest statement}\par
"None of the authors are aware of any conflicts of interest, financial or otherwise, that could, either directly or indirectly, purposefully or inadvertently, affect the development or reporting of their scholarly activity."			 			  				\begin{bibitemlist}{1}
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