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Some fear the Clinton medical-reform plan has too little respect for the doctor-patient bond. The best care, they say, comes from a physician who cares. : A Healthy Dose of Trust

TIMES HEALTH WRITER

Brad and Jennifer Webster spare no time and effort when it comes to their children’s health.

Because their baby son has health problems, the Costa Mesa couple drive more than an hour to Riverside and two hours to San Diego to take their child to doctors with whom they feel confident--and comfortable.

“I like a doctor who says, ‘How are you? How is your son?’ ” says Jennifer. “They should be concerned for the whole person and the whole family. I’m not saying any doctor is perfect. But our doctors put some effort into the relationship. They have excellent bedside manners. I feel a sense of honesty and integrity. Plus, I feel they are competent.”

What the Websters desire from health care--honesty, communication and empathy--are qualities that Americans have generally cherished in relationships with doctors. But as vast new managed-care networks are set up under President Clinton’s health-care reform, some long-standing relationships might be severed as consumers are forced to choose new insurance plans and doctors are pressured into joining managed-care organizations.

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Whether doctors and their patients can forge new personal relationships is among the many unanswerable questions regarding reform.

Some predict a highly impersonal system in which Americans will settle for cordial, competent, yet remote care, somewhat like most car owners have with a mechanic.

Others say good doctors will continue to construct relationships with loyal patients because they know the best medicine can only be practiced in an atmosphere of trust and communication.

“Health care is a combination of science and art. It is complex,” says Dr. Stephen Cohen, a Texas physician who is president of Physicians Who Care. The advocacy group opposes any changes that would remove a patient’s freedom to choose a doctor.

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“It sometimes takes a long time to fine-tune the relationships--to get the most out of them. When these relationships are broken--and they will be under this new setup--it’s going to have adverse consequences.”

The bond will not be forgotten in reform, argues Dr. William Osheroff, a PacifiCare physician. He operates a training program that teaches medical personnel how to build good relationships with patients.

“The need people have for care will not be affected by health-care reform. The reason physicians have for going into medicine--the need to take care of people--will not change.”

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Few would argue that the doctor-patient relationship is unimportant. PacifiCare undertook its sweeping training program, called Art of Caring, because it found that 80% of its members’ complaints had to do with communication or “caring” issues.

“This was stuff like, ‘The nurse was abrupt’ or ‘The doctor didn’t explain fully what he was doing,’ ” Osheroff says. By training everyone from office workers to doctors in courtesy skills, the complaints decreased 40% in a year, he says.

Americans have long put a high premium on good relationships with doctors, numerous surveys show. One study found 25% of Americans switched doctors at some time because of communication problems. These patients complained that the doctors made them feel uncomfortable or did not relieve their anxiety.

Patients often appear at their doctor’s office anxious or depressed. And studies show a significant number of health complaints are emotional or psychological in nature. But unless the physician and patient have a good rapport, the emotional issues may not surface.

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Moreover, patients who remain upset and fearful don’t respond as well to treatment, says Dr. Lexey Parker, a Reno, Nev., physician and women’s health advocate.

“I think Western medicine has always grossly underestimated the mind-body connection,” she says. “The only place we’ve addressed this has been in the doctor-patient relationship.”

Trust becomes the core of a good doctor-patient relationship, says Dr. Malcolm Sperling, medical director of the Edinger Medical Group, a large group practice in Fountain Valley.

Trust, he says, “depends on whether you have an opportunity to establish a relationship. If you have the opportunity to see patients through minor illnesses, then you have the chance to develop the relationship. And if you have a major problem, they have confidence in you.”

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On one occasion, Sperling says, a woman came in with her seriously ill eight-year-old. Sperling concluded that the child, a new patient, had severe appendicitis and needed immediate surgery.

“The mother said, ‘You’re too anxious to operate. I’m leaving,’ ” Sperling recalled.

Ten minutes later, she brought the child back, conceding that she had to trust the doctor.

Relationships with a doctor seem to be more important in certain medical situations, such as chronic or severe illness, patients and doctors say. Men generally are not as concerned with doctor-patient relationships, while women place a high premium on developing a relationship with obstetricians, gynecologists and with their children’s pediatrician.

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When she had serious health problems, Jacquie Balodis says she had to doctor-shop. To her, a nurse and psychologist, a good relationship is one in which the doctor listens as well as talks.

“I want a doctor who is both nice and competent,” says Balodis, 52, of Garden Grove. “One doctor told me to stop playing doctor and be the patient. I wanted to find someone to respect my opinion.”

What Balodis eventually found was a doctor who spent 90 minutes with her at the first visit.

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But under the Clinton health-reform plan, Americans would be forced to leave doctors they are attached to or would be unable to see the same doctor, critics charge.

One poll of L.A. Unified School District employees and retirees, for instance, found that a majority disliked the district’s new prepaid dental plan largely because many members would have to change dentists to get full benefits, according to the California Dental Assn., which sponsored the survey.

And, when the Automobile Club of Southern California switched its health-insurance plan to the HealthNet managed-care plan, many members who had been seeing doctors at the Edinger Medical Group vehemently objected because they would have to give up their doctors at Edinger. The result, says Sperling, is that the Edinger group joined HealthNet.

“There were enough members of the Automobile Club that we had been taking care of for a long time. And they were upset at having to change doctors,” he says. “It’s difficult when you have been getting care from the same person for 10 or 15 years and then have to find a new doctor.”

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The other fear consumers have about the shift to managed care--that they won’t see the same doctor at each visit--may be the biggest problem to overcome, experts say.

“Where the system becomes inefficient is where people bounce from one doctor to another, one system to another, and no one knows what is going on,” says PacifiCare’s Osheroff.

But managed-care plans that assign a primary-care doctor to each plan could improve doctor-patient relationships “because the care is quarterbacked, or coordinated, by a primary-care physician,” says Dr. Sam Ho, vice president and medical director of HealthNet.

Many managed-care plans that were originally based on a “staff model,” in which the patient would see whatever doctor was on call at the time, have evolved to a system of assigning its members to a personal physician, Ho says.

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“People have demanded it,” he says. “And I think it lends itself to better care.”

And, to avoid breaking many longstanding relationships, many doctors will simply apply to become members of as many health-care organizations as possible, so that patients will not have to switch, Osheroff predicts. The only thing that will change is how the care is financed.

But for others, health reform may reveal a very businesslike side of medicine.

Billie McDonough of Chula Vista leaned heavily on the pediatrician assigned by her HMO as tests were run to determine why her 14-month-old daughter was mysteriously failing to develop.

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“Our rapport with him was great. He was very concerned,” she says.

But, in anticipation of Clinton’s health-reform plan, the pediatrician quit the HMO to take advantage of a new employment opportunity. The new pediatrician McDonough’s child was assigned to has referred the child for extensive testing--but they have yet to meet although McDonough has asked for a get-acquainted session. In the meantime, the family is seeing specialists in what they feel is a disjointed, uncoordinated manner.

“If I still had the old pediatrician I would have felt like I had somebody to go to and say, ‘I’m not comfortable with this’ or ‘Could you please talk to Dr. So-and-So about this?’ ” says McDonough. “I don’t feel I have an advocate now.”


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