by Jerry V. Marlin, MD

December 1996

This human relationship continues to be the center of any health care system. The interaction of the physician and patient is not for profit and not predominately a business relationship. The term "customer" should never be used when describing the patient in this relationship. In a managed care system, financial costs and the desire to make profits cause the insurance carriers or third party administrators or hospitals to vary in their views as to who is at the center the patient or the corporation. Attempts to alter and control this relationship can have significant economic, let alone sociological effects.
Both the patient and the physician play a vital role in healing. Open communication is mandatory, not only to begin this relationship, but also to maximize the healing of the patient. To maintain open communication, trust and honesty must prevail. The patient can enhance his or her healing potential through the help and guidance of the physician. Emphasis has been placed on informed patient choice. With good communication, the experience and wisdom of the physician can be the best source of education for the patient. In this information age, Americans are better educated, and additional knowledge is obtained easily and quickly through medical books, the Internet, cable TV, other physicians or people with similar conditions. Without excellent knowledge of the patient's standards regarding quality of like and expectations of treatment, the physician will have difficulty strengthening the relationship and helping the patient heal. The limits of modern therapeutic capabilities, whether by a physician, nurse, therapist or medications, need to be discussed openly. An effective therapeutic plan can best be created through open, two-way communication and a caring relationship.
With an alerted mental status, the patient may have memory loss, impaired judgement or emotional illness affecting competence and ability to understand and make informed decisions. The presence of family members will be required, if available, in such situations. Decisions made for an incompetent or comatose patient by the physician must be in the best interest of the patient. A previous excellent relationship and knowledge of the patient's desires during life or near death become extremely important.
If the patient does not agree with the physician, the physician should be informed. A second opinion is commonly obtained today. If the patient does not follow the physician's advice, the relationship may have changed to the point that further healing will not occur. A physician also should honestly discuss the limitations of his or her ability to help the patient. The evolution of medical care has created multiple specialty services in all fields of surgery and medicine. Referral to a different physician may need to be initiated. The patient trusts that the physician's treatment plan always maintains the goal of finding the best method to help the patient.
Decisions regarding treatment are made based on the diagnosis of the individual's illness or disease. The diagnosis is generally made by clinical judgement and appropriate tests. Clinical judgement has been de-emphasized in managed care. Tests are performed to obtain accurate and objective information regarding the patient's condition. Unfortunately, costly tests also are done to provide documentation as a defensive strategy against future lawsuits, etc., or defensive medicine. On the other hand, due to managed care rules, many appropriate and necessary tests are not authorized by the insurance carrier.
Clinical judgement is required to identify if the abnormal test is relevant to the illness, let alone a part of the natural process of living and aging. If clinical judgement returns to be the strongest tool in the care of the patient, then the patient-physician relationship will be strengthened. Cost-effective tests and treatment may then become the norm again.
When a managed care organization unilaterally decides on the authorization of a procedure or hospitalization, rarely is the physician asked for clinical judgement of the patient's condition. For example, the number of office visits or hospital days allowed or specific tests which may be performed are decided on by an utilization management group with statistical analysis of previous patients with these diseases. Often, health-care professionals who have never touched, let alone seen, the patient are making such decisions. The clinical experience of these managed care professionals varies considerably. Often, physicians treat patients with unique or multifactorial problems. Such outside influence can cause conflict affecting the care of the patient by the physician. Should the physician then be able to discuss the insurance carrier's decisions or managed care restrictions with the patient? Of course!
The initial contact with the physician may be with the office staff or the environment within the office. The first view of the office, staff or doctor can have a direct bearing on the future strength and growth of that relationship. Open communication with the patient is important, but confidentiality must be maintained. Documentation is important for many reasons, especially for future reference. A continuity of care can then be provided. With current computer technology, entire charts can be quickly transferred to another computer for viewing. Should the patient have immediate and full access to his or her chart? Certainly, this would widen the communication channel between physician and patient, but at what consequence? Will the person viewing the entire record interpret the information properly? Currently, when the patient reports to family members the advice given to them by the physician, often only a small amount of information can be recalled and not always repeated in the same way. To avoid errors in communication and enhance this relationship, this may become a new option in health care delivery as we approach the 21st century.