PROLOGUE: “A doctor,” Czech author Milan Kundera wrote in The Unbearable Lightness of Being, “(unlike a politician or an actor) is judged only by his patients and immediate colleagues, that is, behind closed doors, man to man.” Many contend, however, that this intimate dynamic of the relation between physicians and their patients has been forever altered by managed care. Now, demands for accountability to parties other than patients and colleagues—namely, managed care plans and the administrators that run them—have transformed this once-personal relationship into a quasi-business transaction. This has striking implications for the practice of medicine and for its professionalism, writes Brad Gray in this paper. Gray, who directs the Division of Health and Science Policy at the New York Academy of Medicine, has had a long and distinguished career in the health policy arena and academe. Prior to his appointment at the academy, he was an adjunct professor of research in public health and director of the Institution for Social and Policy Studies and the Program on Non-Profit Organizations at Yale University, where he maintains a research appointment. He was a senior staff member and study director at the National Academy of Sciences' Institute of Medicine (IOM) for ten years before beginning his tenure at Yale. While at the IOM he served on the staff of the National Commission for the Protection of Human Subjects of Biomedical and Behavioral Research and the President's Commission for the Study of Ethical Problems in Medicine and Research. He received a doctoral degree in sociology from Yale. His most recent book is entitled The Profit Motive and Patient Care: The Changing Accountability of Doctors and Hospitals (Harvard, 1991). ABSTRACT: Trust is essential to the doctor/patient relationship, but trust in physicians' fiduciary ethic has become less plausible as a protector of patients' interests. The rise of managed care often is seen as undermining the fiduciary ethic and lessening the trustworthiness of care. But can managed care enhance that trustworthiness? Four possible sources of trustworthiness in managed care are discussed: ethical standards in the managed care industry, nonprofit organizations, physician control, and performance monitoring by purchasers. Limitations on all of these fronts suggest the continuing importance of a strong fiduciary ethic on the part of physicians who make patient care decisions.
Bradford H. Gray (Wed,) studied this question.