PERSPECTIVE ON HEALTH CARE : The Bureaucrat Will See You Now : Health plans cut doctor- patient bonds. If doctors become interchangeable and anonymous, patients are likely to be the same.

<i> Brian D. Johnston has been an emergency physician in Los Angeles for many years. </i>

A routine visit to the doctor’s office or clinic today will not reveal the basic restructuring of the relationships between doctor, patient and employer or insurer that have taken place over the past few years.

Quite apart from the changes contemplated in Washington, American medicine is becoming industrialized, bureaucratized and depersonalized to a degree that few would have imagined five years ago. These changes will have direct personal consequences for us all when we really need health care, and they are occurring with little public awareness or understanding.

Medicine has traditionally been a one-on-one encounter centering on the doctor and patient. The patient sought the knowledge and skill of the physician, who became an advocate and champion for the patient. The physician referred to the patient as “my patient” (that may sound patronizing, but it at least declares ownership of the outcome). They got to know each other; the doctor explained the illness and embarked upon a course to cure or at least alleviate the problem. The doctor selected the drugs, the hospital, perhaps the surgeon and other specialists, and was responsible to the patient for these choices.


It was a very personal, sometimes emotionally draining process. Patients confided their deepest fears. Doctors kept their confidences safe and shared the burden with them. Oddly, this kind of relationship was more prevalent when doctors had less to offer in the way of cure. Despite comparatively meager results, physicians were revered and patients were treated as individuals.

Now, increasingly, things are different. The physician is often selected from a list provided by the insurer. The doctor may be charged with making a diagnosis and proposing a cure, but now he or she doesn’t work for the patient--the doctor works for the plan.

The patient, instead of buying insurance to pay the doctor, has bought a plan. The principal relationships of doctor and patient are not with each other, but with the plan. The plan has more control over the physician than the patient does. The doctor doesn’t set his or her schedule and can’t control the time allotted a given patient, or even which patients he or she will see. There are restrictions on what tests and treatments can be ordered. If the assigned doctor recommends surgery or a diagnostic procedure, it will be “reviewed” before it is “authorized.” The “review” may well be done by someone with little or no medical training, who doesn’t know you, your disease, your circumstances, your doctor or the proposed procedure. The reviewer is often given incentive by the insurer to delay or deny authorization.

Your physician is now “profiled” by the managers of care to ensure “productivity” and “cost effectiveness.” The managers are inclined to see physicians whose cost of care for a specific illness is high as “bad,” and those whose cost of care for the same illness is low as “good,” regardless of the fact that the “bad” physicians’ patients might be sicker, thus needing more care, or the “good” physician might be denying patients legitimately needed care. It is far more difficult to stand up for your patients when you’re being “profiled” by an employer who controls your economic fate.

What we are doing is rapidly replacing physician control of health care with control by administrators, bureaucrats and businessmen. We are doing so despite the fact that the new controllers may not be medically trained, have no knowledge of or connection to the patient and profit by withholding services. We are doing all this to control health-care costs--something we all acknowledge we must do.

Business, government, insurers, hospital administrators and even some nurses have greeted these changes with enthusiasm. Physicians are told that if they don’t join one plan or another, they will be outside the health-care system, with no patients at all. Proponents of the integrated systems ridicule one-on-one medicine, even though each of us, if we ever get sick, wants to be treated as an individual, by another individual who is answerable to us and our family.


President Clinton touched on this issue when he promised that under his plan, each of us would be able to choose our own doctor. But the choice of a doctor is meaningless if the “contract” is with a plan, not the doctor, and if the doctor is so bureaucratically constrained as to be a mere functionary in a cost-driven system. More and more people in large plans are finding that when they’re really sick, their doctor is not in a position to get them what they really need.

This is not to say that all large, integrated systems are bad.. Kaiser, the Palo Alto Medical Foundation, Mayo and others have earned good reputations for medical care. And this is not to say that physicians’ actions should never be reviewed. But the review should be by competent, medically trained persons whose sole objective is not cost-cutting. Better medical care will result when physicians are allowed the professional autonomy to make sound professional judgments based on individual patients’ needs, and then held individually accountable for those judgments.

We must contain the cost of health care and extend coverage to all, but we must also insist that physicians be free to use their considerable knowledge, skill and training to our benefit. It is clearly in our self-interest to do so. We should choose systems that promote a close personal relationship and personal commitment between doctor and patient and hold the physician responsible for the outcome of care. If doctors become anonymous and interchangeable, the same thing will happen to patients.

Polls show that the vast majority of patients are satisfied with their doctors. That’s not the problem. Cost control and universal access are the real problems. As we go forward with reform, we should preserve the “contract” between patient and doctor, while expanding access and controlling cost. If we don’t keep that focus, we will pay our premiums only to find that we have bought a bureaucratic nightmare.