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Perspectives |
1 From the Department of Radiological Sciences, University of California, Irvine Medical Center, Orange. Received October 7, 2002; accepted October 16. Address correspondence to the author, 18961 Castlegate Ln, Santa Ana, CA 92705 (e-mail: rmfriede@uci.edu)
Index terms: Economics, medical • Perspectives • Radiology and radiologists, socioeconomic issues
I have written previous Perspectives on managed care which stressed that we are in a period of evolution in the practice of medicine, and the managed care of the late 1990s will continue to evolve over the next 20 years (1–3). Initially in the early 1990s, most physicians were against the concept of managed care, but too much of that resentment was directed at the threatened loss of income and control of their practices. These are management concepts that the businessman fully understands, and physicians had little chance of influencing the direction of managed care, which is based on the concepts of income and control. Too few physicians emphasized that the major effect will be on the patient and that over the long haul, regardless of management desires, the patient will have the major voice in the future of health care. Although many of the principles of managed care, such as the emphasis on preventive medicine, are certainly desirable, the future evolution of health care will be driven by the conflict patients have with the humanistic aspects of managed care today. These include many of the management decisions that affect patient-doctor relationships such as waiting time, access to consultants, ability to contact physicians, and time spent with physicians, all of which form the basis of a patient-doctor relationship that managed care has sacrificed without patient consent for the sake of efficiency.
Kenagy et al (4) make the analogy that most patients judge health care as they would an airplane flight. They assume that the airlines are reliable and are run by technically competent people. They judge the airline by more personal criteria, such as comfort, helpful friendly personnel, and on-time schedules. Most patients cannot judge a physician’s knowledge or skill, but they judge their health care on the basis of other dimensions that relate to areas that they personally know and value. Businesses that provide competitive services would be unable to survive if they treated customers with the levels of waiting, unanswered questions, and inconvenience that are the norm in health care. Kenagy et al believe that pleasing the patient improves the outcome and clinical satisfaction and can be cost-efficient.
In my opinion, deterioration of the patient-doctor relationship started after World War II, when multiple technologic advances led to increased specialization in medicine. Patients were increasingly referred to consultants, which diminished the relationship with their personal physicians. The patient-doctor relationship also suffered when corporate and group medical practices became common, and patients might not always see the same physician on subsequent visits. The concept of physician corporations seems to have moved medicine from an individual practice to a big business where finances supercede patient-doctor relationships. The major effect occurred in the 1990s, when managed care made the insurer responsible for patient management and the physician responsible for patient treatment. This division severely damaged patient trust in the system. Physician involvement in patient management is fundamental in developing patient trust, which is necessary for the patient to accept that the physician is knowledgeable and reliable and can be trusted to recommend the proper therapy.
The development of trust in the physician leads to a proper patient-doctor relationship and is part of the healing process. When management dictated "the rules of engagement," patient resentment increased as the patients no longer felt that they could rely on their physicians for total care. Patients began to feel that their primary care physicians were restricting their access to specialty care and in effect were rationing their care on behalf of profit-orientated managed care plans. Grumbach in 1999 (5) noted that 25% of patients had been forced to change primary care physicians in the previous 2 years because of changes in their medical insurance plan. A major element necessary for patient trust is continuity of care with an individual physician. A major factor stressed by Sherger (6), which managed care providers do not seem to appreciate, is that diseases do not come for treatment, people do. Patient care is fundamentally based on human interaction, and healing requires such relationships. He stresses that patients do not care how much a physician knows until they know how much the physician cares. Trust in the physician is formed from patient-doctor encounters. The level of trust is used by the patient to judge the physician’s knowledge or skill (7).
Trust is difficult to come by, and it is fragile. Trust that has been built over years can be dashed with one bad experience. Illingworth (8) states that the level of trust that the patients have in their doctors and in the institution of medicine itself has been impaired by managed care. He believes that trust is a form of social capital and should not be left in the hands of organizations that are concerned primarily with meeting their fiduciary duty to their stockholders. Patients are forced to trust professionals since they do not have the ability to judge the physician’s knowledge and skill (8). They trust that the physician treating them possesses the capacity to help and heal.
Patient trust starts with the way the physician relates to his or her patients. If the visit with the primary care physician is harried, questions will not be answered, patient comfort will not be achieved, and trust is diminished. When patients attempt to contact their physicians and have their questions fielded by a clerk who may be intrusive and demand information that the patient feels should be asked by the physician, trust diminishes. When patients feel that their doctors prevent them from seeing a consultant, trust diminishes. Good communication between patient and physician is necessary not only to avoid complaints and reduce the risk of litigation but as a part of the healing process. The vulnerability of patients and their need for care force them to trust physicians. If this trust is to increase, it must be an interactive process and requires care, concern, and compassion from the physician.
I should emphasize that all managed care organizations and all physician and hospital providers are not the same. Patient relationships vary in different groups. Satisfaction with managed care is usually high in those who are healthy and are lower in those who are ill, particularly those with chronic diseases. If one wants to assess patient satisfaction with managed care, one should not ask healthy patients who see their doctors once or twice a year but should ask patients with illnesses who have to cope with a difficult system.
Kenagy et al (4) point out that the U.S. health care system is the world’s largest service industry, and it excels in its capacity for treatment of serious illness. Despite this, however, physician satisfaction, respect for physicians, and trust in our health care system are declining. Polls conducted in 1994 (9,10) reveal that 75% of Americans felt that our health system requires fundamental change, and 84% said that there was a crisis in health care. The crisis relates to the lack of availability of health insurance, accelerating costs, and quality of care and service from managed care providers.
Siegler (11) divides the history of the patient-doctor relationship into three periods: the age of paternalism, which was the age of the doctor; the age of autonomy, which was the age of the patient; and, last, the age of bureaucracy, which is the age of the payor. Siegler believes that the age of paternalism lasted for more than a thousand years, from about 500 BC to 1965. The physician was in charge, and the patient trusted the physician’s technical skills, morals, and ethics; this was characterized by patient dependency and physician control. Medicine provided symptomatic care rather than cure during most of this period, but it satisfied many basic human needs for most patients.
The age of autonomy (11) lasted less than 50 years, from 1945 to the 1990s. This was an age of extraordinary advances in the understanding of disease and development of treatments. In this age, the emphasis was on treatment rather than prevention and on cure rather than care, and treatment was very expensive. The balance of power shifted from physician to patient, with demands for patient sovereignty and freedom from paternalism and the development of a patient-doctor relationship that is based on patient rights and informed consent.
In the present age of bureaucracy (11), cost containment and cost-efficiency are based on societal risk-benefit analysis. This age is basically defined by the cost of care, which is easy to quantify, rather than by the quality of care, which is hard to define. In this period, a shift occurred from individual needs to society needs. This shift necessitated individual patient rationing, which in turn necessitated external control over the patient-doctor relationship. An attempt was made to broaden access so that the costs for more individuals would be covered; however, in order to control costs, treatment of the chronically ill, the disabled, and the elderly became somewhat compromised (11). The wishes of both patients and physicians become subservient to the wishes of administrators and bureaucrats.
Siegler (11) believes that clinical and ethical decisions in medicine are based on the following considerations: medical indications, patient preferences, quality of life considerations, and external factors. The patient usually accepts the physician’s proposal or negotiates a modification of the proposal on the basis of the doctrine of informed consent. Prior to 1990, the vast majority of clinical and ethical decisions were based primarily on medical indication and patient preference, with little consideration of cost or scarce resources. In the current age of medicine, decisions must undergo external review and oversight because of the concept of "marginal benefits" (11). Earlier, patients and doctors tried to maximize marginal benefits, even with a 1% chance. With managed care, the pursuit of marginal benefits is restrained, which then limits both physician and patient autonomy.
Siegler (11) believes that there are five major ways in which patient and physician autonomy and self-determination are limited. (a) End-of-life decisions: Patients can always say enough is enough; however, if they want expensive end-of-life care and it is judged futile, they may not receive it. (b) The futility standard: If the insurer believes that a 3%, 5%, or even 15% chance of success qualifies as futile, then life-sustaining attempts can be limited. This is a shift from a personal standard of care to an externally imposed standard. Patients are most interested in the possibility of success rather than the probability, but the possibility may be judged as futile. (c) Quality of life standard: If the quality of life is very bad, the insurer may decide it is not worth pursuing successful treatment. This of course is a dangerous assumption; quality of life is an individual perception. When the insurer’s decisions are imposed on the patient, there is the possibility of a future slippery slope. (d) Social utility: In managed care, the implication is that a physician should know when a patient is dying and not waste valuable resources. In real life, however, physicians are often unable to decide if a patient can be saved. If the decision is imposed as an external standard, the rights of patients and doctors to make decisions are limited. (e) Practice guidelines and clinical paths: Guidelines were proposed by managed care to assist medical decision-making, but some physicians may use them as decisions for treatment. The problem is that patients may not all have the same response to diseases and treatment; therefore, an individual may not respond according to guidelines.
The primary care physicians must help coordinate care and guide patients to have access to sophisticated diagnostic tests and interventions (12). Primary physicians play a major role in screening and prevention for all patients. To be successful, the primary care physician must establish a relationship with the individual. The physicians must help patients enjoy life and live their lives in a manner of their own choosing. They must attempt to improve the lives of patients, and when this is no longer possible, they must ensure a death that is compassionate. It is difficult in the time allotted for the physicians to provide the necessary advice and treatment while also providing the humanistic values that are part of the moral responsibility that physicians accept when they enter the field of medicine (12). To accomplish these responsibilities within the limits of managed care is extremely difficult, but hopefully the need for these humanistic values will be realized as medicine undergoes evolutionary changes in the next generation.
From the legal viewpoint, it is generally acknowledged that there are three major dimensions to the patient-doctor relationship (13). The first dimension is contractual: Once a relationship is initiated, it is subject to the principles of the law of contracts. Second, in a consensual relationship, doctors are required to obtain competent informed consent from their patients before care and treatment can be provided. Third, quality assurance concerns require that the doctor apply appropriate standards of care in providing service to the patient. Doctors have become subject to fiduciary law, which acknowledges that in certain legal relationships where one party is more powerful than the other, the more powerful party, in this case the physician, is subject to a higher standard than is imposed by traditional principles in the law of contracts or torts.
The standard reflects the relationship of special trust in which one party is more vulnerable. Decisions of the fiduciary (the doctor) must be for the well- being of the patient and not for the benefit of the doctor. This was the original concept in "medical paternalism." Today, the authority for decision making has been relocated to the individual; therefore, we now practice "guided paternalism," in which the final say resides with the patient, with physician advice and guidance about what should be done in a particular situation. For this to work, the patient must trust the physician. Without trust, many patients may not be able to make the medical decisions that would serve them best (14).
Patient-doctor relationships are not emphasized in medical school. Haidet et al (15) attempted to measure medical students’ attitudes toward patient-doctor relationships. Students entering medical school were highly idealistic, but Haidet et al noted that this idealism declined after the first 2 years. In the later years, doctor-centered rather than patient-centered attitudes developed, and students become more paternalistic toward patients, which decreased patient satisfaction. When physicians enter managed care, the associated clinical pressure forces the physician to become more disease oriented and even less patient centered. Cohen (16) emphasizes that medicine is still a moral enterprise. Many doctors have become disappointed or disillusioned by the declining income and loss of autonomy and by the facts that they no longer command respect, they do not have enough time to listen or care for their patients, and the malpractice problem is increasing. These issues also lead to less patient-centered attitudes and diminish the patient-doctor relationship.
In medicine, basic economic laws must be observed, and practices must be run on a sound financial basis to survive. Nevertheless, changes that improve patient care will be adopted in the future despite increased costs, simply because they are what people want and will demand. Medicine will always need to be subsidized as a social program. Medical care is more than a business, and politicians must accept it as such. Although some limitations on free choice are essential to control costs, these limitations must be secondary to improvements in patient care.
In this Perspective, I have tried to stress that the scientific aspects of care are always delivered in the context of a personal relationship, the patient-doctor relationship, which is based on a healing bond of trust between a patient and a physician and serves the needs of both. Managed care has damaged this relationship, and both physicians and patients must insist on its restoration. The patient-doctor relationship is as fundamental to the art and science of medicine as are drugs and technologic advances. Managed care in the United States is becoming a political struggle, and the type of future care that evolves will be decided by the people. The U.S. Congress may be reluctant to become enmeshed in health care politics, but they must assume this responsibility. Hopefully, the final compromise will be practical and patient friendly.
REFERENCES
This article has been cited by other articles:
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  R. M. Friedenberg Malpractice Reform Radiology, April 1, 2004; 231(1): 3 - 6. [Full Text] [PDF]
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