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By Irwin Hassenfeld, M.D.
The primacy of the physician-patient relationship has long been recognized as the bedrock of good medical care. The integrity of this socially important dyad is, however, seriously threatened by economic and technological developments.
The relationship between the profession of medicine and the business of medicine always requires a delicate balancing act. For most of its history, medicine has maintained that professional values trump the bottom line. In the past, when the welfare of an individual patient required a medical intervention that neither the patient nor the patient's family could afford, a way was usually found to make it happen. With the advent of prepaid medical insurance, which has all but replaced fee for service, and with for-profit hospitals and managed care companies controlling a rapidly growing segment of medical care, this is no longer the case.
The health care of individual patients as the paramount concern is being replaced by concern for the welfare of corporate stockholders.
Contributing to the erosion of the doctor-patient relationship is the disappearance of its confidential nature. Managed care companies demand that physicians provide extensive patient information in their quest for fiscal accountability. Computerized medical records are increasingly centralized by merging huge health care conglomerates, making sensitive patient data vulnerable to illegitimate use.
Paralleling the increase in economic pressures is the technological explosion, which has made possible diagnostic and therapeutic interventions unimaginable only a few years ago. The down side of the technological revolution has been the replacement of bedside examination with laboratory numbers and radiographic pictures. Physicians seem more and more reluctant to touch, be touched by, and get in touch with their patients. Recently, stethoscope manufacturers have responded to physician demands, according to an article in the February 17 New York Times, by lengthening tubing, thus allowing doctors literally to keep patients at arm's length.
In the decades leading up to the Nazi period, German medical care was being altered in ways that may have contributed to the utter abandonment by German physicians of Hippocratic ethics and professional principles. Patient privacy disappeared as doctors became investigators and informers for the state. Commercialization and bureaucratization of medical practice took place, as the Weimar Republic put in place a program of universal health care and cradle-to-grave coverage. Perhaps the most enabling change on the road to patient extermination occurred in 1926, when German physicians officially shifted their primary allegiance from individual patients to the "health of the nation".
It is therefore disturbing to hear medical ethicists label as outmoded and obsolete the notion that physicians' primary obligation is to advocate for individual patients. They propose, instead, that physicians have as their primary responsibility the health of designated populations and communities, an idea strongly endorsed by many HMO officials. While I believe that someone should be looking after the welfare of populations and communities, it should not be the primary concern of practicing physicians.
Although I am convinced that our strongly democratic society makes the Nazis' cost-containment methods highly unlikely here, our patient care can be, and may already have been, affected negatively by the developments described above.
The solution to this crisis lies in physicians' refocusing on the health and welfare of individual patients and opposing, politically if necessary, the forces that undermine professional values. Countering the tendency of physicians to distance themselves from their patients will require thoroughly rethinking medical student and resident education. It would be appropriate for psychiatrists to lead the way. Unless we address these problems, American medicine is in danger of losing its soul.