Diagnosis for Democracy
Insights into the State of Our Union
A Blog by Rob Tenery, MD


January 10, 2013: The Physicians' Vanishing Covenant

By Rob Tenery, MD on January 10, 2013

The patient/doctor relationship began as an act of beneficence--- the process of sharing one’s knowledge with another in need. There was no formal contract. Instead of a handshake, the offer was a helping hand. The ultimate goal was one of good, and not for any reward that might come out of the encounter.

The relationship was an unwritten covenant between the doctor and the patient. It was based on trust. Trust that the doctor would always put the patient’s best interests first. Trust that the doctor would use his/her skills to apply the best diagnostic and therapeutic options available or refer the patient to where those alternatives would be available. Trust that the doctor would never abandon the patient.

Then things changed. The doctor had to ‘make a living’. What was once a relational union between the doctor and the patient began to slowly evolve into one based on a transaction--- an exchange between two consenting parties. Those patients, that couldn’t afford to offer anything in return, still received proper care.  Those, with the means to pay more, did--- the exchange of skills and knowledge for whatever the receiving party could afford. In those early days it could have been a bushel of corn or a prized farm animal. Later it was more often currency. In spite of this evolution to a transactional relationship, the covenant between the doctor and the patient still stood firm. That was until the third parties became involved. At first, it was private health insurance (later to become Blue Cross/Blue Shield) and the federal programs (Medicaid and Medicare). Even then, it was not until the federal programs started dictating how much the physicians should be paid was that covenant tested.

The growing threat of repercussions from poor results rather than just negligence put this union to the test. But it was managed care, especially under the rules of capitation that this once-sacred relationship began to falter. Under these restraints, the physicians were now forced to recognize the needs of all patients within a particular funding system. No longer was it just about the one patient. Because of an expanding patient base, coupled with growing funding and resource limitations, physicians they were incentivized to do less, and sometimes penalized for doing more.

Along the way, the tide also changed in physicians’ attitudes. No longer was medicine ‘their life.' What was once a calling to most who had chosen the medical profession, was becoming their vocation. Not because they were any less dedicated to their patients, but because of the advances in technology not only within the profession, but in the areas of telemedicine, cross-coverage and communication had freed them to devote more of their time to their families and other interests. The very technology that has advanced health care to the highest level in the history of mankind was gradually stripping the emotion out of the relationship.

Instead of a stethoscope, an ophthalmoscope and a reassuring pair of hands to probe for underlying pathology, many physicians of today turn to their monitors for answers. Have these advances raised the level of care? Unequivocally YES! If the question was changed to read the level of caring, the answer would be a resounding NO!

A change in patients’ expectations also has played a part. Increasingly, patients are basing their judgments on outcomes and rather than efforts. Not that the trend is totally wrong, but in a science that is still in its infancy, much is still unpredictable. The patients did not come to feel this way on their own. Marketing of health care services have planted the seeds of unrealistic expectations. The media, in its attempt to inform, has failed to paint the whole picture. Finally, the ravenous, legal community stands by, like vultures, watching for the last breath to scarf up the remains.

Most of the rhetoric espoused during both the political conventions this past summer followed traditional party lines. One thought that went right by me, until it was pointed out by a commentator, was the importance of the family. In his acceptance speech for the nomination for President, Governor Romney said that outside of one’s chosen religious beliefs, the issues affecting the family unit were central to everything. This precept goes back to the basics of problem solving in mathematics--- reduce the problem to its lowest common denominator. That similarity to our priorities in health care struck a note! Heath care reform, insurance coverage, pre-existing conditions, liability concerns, fees---- the list goes on and on. With all of them, preserving the sanctity of the doctor/patient relationship must be central to everything debated in Washington, in the corridors of our hospitals and in our offices. It doesn’t matter whether it is the advances in the science, the fear of legal jeopardy, regulatory intervention or who’s paying the bill, that relationship must remain inviolate.

Not only do physicians put themselves in legal jeopardy, they also incur scorn from the medical community when they abandon their patients. Abandonment doesn’t always have to be just physical separation. Frequently overlooked are the deleterious effects when the loss of connection is emotional.

When patients refer to their doctors, but can’t recall their names. When doctors only remember their patients by their diagnoses. These examples may be signs of emotional abandonment by either party. Even more important, the physicians have failed to uphold the covenant our forefathers first made with their patients many years ago.




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