Throughout the current contentious national debate over Obama Care, it is clear that people do not want to lose their primary care physician. Those who are happy with the physicians (primary care and specialists) in their current health insurance plan do not want to be forced to change to another plan with a different panel of doctors. Despite the complexity of modern health care delivery and the many insurance plan options, people want to see “their” doctor when they are sick.
Why do patients get so attached to “their” doctor? A founder of modern bioethics, Edmund Pellegrino, wrote extensively on the doctor-patient relationship and described the dynamics of the encounter. A patient who is ill goes to the doctor’s office. In her vulnerability, she describes her symptoms and often reveals some very personal information about herself. Without fear or shame she exposes her very body in its nakedness to the physician, confident in the doctor’s professional glance.
For his part, the doctor promises to help and to use his expertise to treat the patient to the best of his ability. At this point in the relationship there is a great dichotomy between patient and doctor. The patient is vulnerable and has diminished control over her body. She trusts her physician and places her health in his hands. The physician has the expertise and skills of his profession to examine, diagnose and treat the patient. He accepts responsibility for the patient’s medical care and tries his very best to help his patient. The healing process may take any of three routes. The patient may be returned to complete health, or if not cured, the medical problem may improve; or if neither is possible, at the very least the patient will be relieved of pain and made to feel comfortable. In all three cases, the physician fulfills his promise to help. Even in hospice care, with the help of family, nurse and physician, the patient regains her dignity and self-respect.
Many contend that Pellegrino is “old fashioned” and places too much emphasis on the phenomenology of the physician-patient encounter. Perhaps he fails to recognize the larger context in which medicine is practiced today. The success of modern medicine has been due to the increasing scientific basis of medical knowledge and technology. At the same time, the traditional understanding of professionalism has eroded in contemporary society. Perhaps older professional models of the physician, and the physician-patient relationship, are no longer operative in contemporary medicine.
Pellegrinos’ critics argue that medicine is a social practice and not simply a one-on-one encounter. In an age of high-tech medicine, physicians and patients are not alone when they encounter one another in the clinic. Their encounter involves many other health care professionals, insurers, clinical and hospital administrators, legislatures and regulators. Medicine is a social practice and not simply a one-on-one encounter.
Health insurers have assumed an ever increasing presence in the clinic, specifying what tests can be done, what medicines can be prescribed, and where the patient can be hospitalized. Indeed, some health insurance policies remove the personal physician from the examining room entirely and replace him with another on their approved panel of physicians. It is unclear how Obama Care will impact the physician-patient relationship. Although it’s the insurance plan, and not Obama Care per se, that determines the network of doctors and hospitals to which a patient would have access, Obama Care exerts a powerful influence on the type of insurance plans that are available. Thus there is no guarantee that a patient will be able to keep his personal physician under Obama Care.
America cannot afford the ever increasing costs of health care. American’s hunger and blind acceptance of ever new and expensive medical technology, along with the realities of scarcity and the need to allocate resources, raise fundamental questions about how medicine is understood and practiced today. Inevitably costs are affecting the physician-patient encounter. Although doctors are reluctant to place limits on the care of the individual patient before him, they realize that the die is cast and the purity of the physician-patient encounter is forever threatened.
The challenge is to maintain the “art of medicine” despite drastic changes in the social context of medicine. In so far as this is possible, “old fashioned” medicine will not die.