Are Physicians Obligated to Provide Preventive Services? DONALD W. BELCHER, MD Preventive care is c o n s i d e r e d a benefit to the pattent. Physicians express a p o s i t i v e attitude t o w a r d s p r e v e n t i o n , b u t t h e i r p e r f o r m a n c e o f r e c o m m e n d e d activities is low, a s s h o w n i n a f i r e - y e a r trial a t the Seattle VA Medical Center. The release o f the U.S. Preventive Services Task Force's g u i d e to clinical p r e v o t t i v e services h a s p r o v i d e d p h y s i cians with authoritative p r e v e n t i o n r e c o m m e n d a t i o n s . While m o s t p b y s i c t a n s a r e specialists with little i n t r u s t o r
skill in preventive care, primary care providers do accept a n obligation to p r o v i d e c o m p r e h e n s i v e care, i n c l u d i n g p r e v e n t i o n . This p a p e r e x a m i n e s the ethical basis f o r the idea o f obligation. E x t e r n a l pressures, legag economic, a n d o r g a n i z a t i o n a ~ a r e affecting the p h y s i c i a n - p a t i e n t relationship in ways t h a t e n c o u r a g e a c o n t r a c t m o d e o f medical p r a c t i c e a n d limit physicians" ability to p r o v i d e p r e v e n t i v e care. As a p r o f e s s i o n , medicine needs to s p e a k f o r the health needs o f the public. As practitioners, physic i a n s n e e d to seek the weO'are o f t h e i r patients. Key words: prevention,, obligation,, p h y s i c i a n - p a t i e n t relationship. J GEN INTERN MED 1990;5(suppl):S104- $107.
T o UNDERSTANDa physician's obligation to p r o v i d e prevention services, the historic relationship b e t w e e n d o c t o r and patient in its ethical dimension n e e d s to be examined. What do physicians owe their patients and society?~, 2 Are physicians e m p l o y e e s of a system, private contractors, or professionals like architects or lawyers, or are physicians part of a long line of healers w i t h a priestly function, e v e n w i t h o u t a theology? In preventive care, one must look b e y o n d science and technology to the heart of the interaction o f physician and patient.
PHYSICIANS' PREVENTION BEHAVIOR A recent five-year randomized trial involved 1,200 male Seattle VA Medical Center outpatients to test w h e t h e r activating patients or motivating physicians w o u l d increase preventive services. 3 This trial tested three innovations: a chart flowsheet; patient e d u c a t i o n w i t h a mini-record; and a health surveillance clinic. Seattle VA Medical Center physicians agreed in baseline surveys that the small set of r e c o m m e n d e d a c t i v i t i e s - - b l o o d pressure m e a s u r e m e n t , fecal occult b l o o d testing, cholesterol screening, influenza vaccina-
Received from the Division of General Internal Medicine, University of Washington, and the Veterans Administration Medical Center, Seattle, Washington. Presented at the conference, Frontiers in Disease Prevention, Tile Johns Hopkins University, June 5 - 6, 1989. Supported in part by the Department of Veteran Affairs. Address correspondence to Dr. Belcher: General Internal Medicine Clinic (111M), Seattle VAMC, 1660 Columbian Way South, Seattle, WA 98108. Reprints are not available.
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tion, and inquiries a b o u t alcohol and t o b a c c o u s e - w e r e appropriate. However, chart audits s h o w e d that only 2 0 - 25% of patients received these services. The one e x c e p t i o n was b l o o d pressure checks, p e r f o r m e d chiefly b y nurses at patient check-in. W h e n apprised of this gap b e t w e e n intention and p e r f o r m a n c e , physicians reiterated their s u p p o r t for the c o n c e p t of preventive care and the i m p o r t a n c e of e x p a n d i n g prevention. Each patient in one e x p e r i m e n t a l g r o u p r e c e i v e d an individualized list of r e c o m m e n d e d p r e v e n t i o n activities and was asked to s h o w it to his doctor at the n e x t visit. Virtually no patient m a d e use of his or her guidelines. W h e n asked why, m a n y stated that " m y doctor should k n o w w h a t is best for m e " or "this sort of thing is the doctor's job." Many patients are not yet ready to assume an assertive role to obtain preventive care, so doctors still n e e d to take the initiative. A t e c h n i q u e designed to trigger physician response was used w i t h o n e trial group. A flowsheet w i t h checkoff b o x e s for each of the r e c o m m e n d e d p r o c e d u r e s was inserted on the inside front c o v e r of a patient's chart. Charts w e r e audited annually for five years to see w h e t h e r the flowsheet was used or w h e t h e r the physician p r o v i d e d any of the r e c o m m e n d e d activities. Results of this trial w e r e disappointing. E x p e r i e n c e d physicians, all in salaried positions, c o n t i n u e d to p e r f o r m at their baseline levels, despite e x p o s u r e to recent prevention information and central administration exhortations to do more. At first it was assumed that the l o w rates w e r e cause by specialists w h o focus on limited p r o b l e m s . While medical subspecialists p e r f o r m e d certain preventive activities relevant to their fields, they often v i e w e d additional efforts as b e i n g outside their service domains. Psychiatrists stated that they never p e r f o r m e d physical examinations at visits and wished s o m e o n e else w o u l d p r o v i d e p r e v e n t i v e care. Surgeons n o t e d that their i n v o l v e m e n t w i t h patients was typically short-term and that they w e r e highly trained specialists w h o did not do p r i m a r y care. Unexpectedly, the general internists also failed to e x p a n d preventive care over the entire five years. The level of services r e m a i n e d stuck at the baseline prevention level. In D o c t o r s ' D e c i s i o n s a n d t h e C o s t o f M e d i c a l Care, John Eisenberg describes h o w hard it is to change physicians' practice behavior. 4 Several papers presented at the Montreal s y m p o s i u m on i m p l e m e n t i n g preventive services 3 suggest that no a m o u n t of consensus building, training, feedback, or s u p p o r t resources is likely to w o r k unless the physician is motivated to act.
JOURNALOFGENERALINTERNALMEDICtNE,Volume5 (September/OctoberSupplement), 1990
ETHICAL FRAMEWORK FOR PHYSICIAN'S OBLIGATIONS TO PATIENTS Consideration of a physician's obligation to patients goes to the heart and p u r p o s e of the medical profession, its role in society and history, 5 and that intimate and mysterious b o n d b e t w e e n patient and physician. Physicians are t e m p t e d to o v e r l o o k the ethical, philosophical, and religious aspects of their responsibility, as individuals and as a profession. Health care professionals n e e d to ask, "Are we thinking of our patients? Do w e really put o u r patients' welfare first?"6, 7 An obligation can be variously defined as a promise, a duty, a contract, or a responsibility to p u r s u e the patient's interest by following a course of action that is shaped b y society, knowledge, law, or conscience. A physician's relationship to patients can be described as fiduciary, because doctors are e x p e c t e d to act in the best interest of the patient. ~ The H i p p o c r a t i c oath speaks of entering into a p h y s i c i a n - p a t i e n t relationship " f o r the good of the sick to the utmost of m y p o w e r s . " In classical times, the relationship b e t w e e n the physician and the patient was s u r r o u n d e d b y spiritual significance and obligation. Great physicians of the middle ages, Christian, Jewish, and Islamic, provide e x a m p l e s of those w h o offered skillful and sacrificial care. St. Bartholomew's in London, f o u n d e d in the 12th century, has a h i s t o r y o f c a r i n g for lepers, the poor, and those with the plague. Just to n a m e m a n y American h o s p i t a l s - - s u c h as C o l u m b i a Presbyterian, St. Luke's, Providence, Mount Sinai, Beth Israel, C h a r i t y - - reminds us that they w e r e founded b y p e o p l e motivated by religious compassion.
THE PHYSICIAN-PATIENT RELATIONSHIP: COVENANT OR CONTRACT? What is the nature of the relationship b e t w e e n physicians and patients? Is it a covenantal relationship or a legal contract? In what sense is a physician different from a building contractor? Mark Siegler points out that the traditional d o c t o r - p a t i e n t relationship is a covenantal m o d e l based on promise-keeping, fidelity, indebtedness to society, and justice, not a contractual model.9 Covenants involve a c o m m i t m e n t to k e e p working, not to do only the m i n i m u m , or w h a t is c o n v e n i e n t or easy. I m p l i c i t in the covenant relationship is a gift, a promise, or a special relationship rather than a p a y m e n t for a specific job. The gift conveys a sense of special obligation. God p r o m i s e d a land to his chosen p e o p l e and invited t h e m to be o b e d i e n t to his law. Marriage vows as a covenant r e p r e s e n t a lifelong c o m m i t m e n t , in sickness or in health, in riches or in poverty. Much of the m o d e r n practice and e c o n o m i c s of m e d i c i n e is moving toward a contractual model. A contract has legal connotations with its stipulation of actions required of b o t h parties, boundaries of work, and penalties for failure of either party to perform. The
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contract m o d e l encourages litigation and impoverishes the p a t i e n t - p h y s i c i a n relationship. Moreover, patients lack the technical k n o w l e d g e to make t h e m an equal party to a medical contract. 9
PHYSICIAN INDEBTEDNESS TO SOCIETY AND THE PATIENT William May reminds us in his illuminating article, "Code, c o v e n a n t , contract, or p h i l a n t b r o p y , " that as physicians we o w e an incalculable d e b t b o t h to patients and to s o c i e t y ) ° Physicians are blessed with immense privileges and power, as well as considerable material reward. 6 Doctors do well to consider the gift of trust received in patient relationships. Such an appreciation can motivate and sustain us in caring for the patient " t o the utmost of our p o w e r s . " We have only to recall o u r earliest patients to recognize our indebtedness and to better a p p r e c i a t e o u r title " p r a c t i t i o n e r . " I especially r e m e m b e r Mrs. Mapp, m o t h e r of ten children, w h o m I visited as a second-year medical student in her "South Philly" h o m e or joined in her visits to the University Hospital pediatrics clinic. She was most polite and respectful to an u n m a r r i e d intern's advice about a feeding schedule for her infant, but w h e n he b e n t to write, she turned and gave m e a large wink. It was m y first observation of the p o w e r of patients in a m b u l a t o r y care and h o w important it is to a c k n o w l e d g e their c o m p e t e n c e and preferences.
PATIENT ROLE AND EXPECTATIONS The lay person relies on the physician's expert fund of k n o w l e d g e and experience, w h i c h is largely one-sided. He e x p e c t s doctors to show concern, to be of practical service, and to provide the same quality of care they w o u l d render to a colleague or to a relative. W h e t h e r patients expect, w e l c o m e , or act u p o n preventive care advice is another matter. Physicians are partly to blame, since they have only recently b e e n willing to enter into a dialogue w i t h their patients, x~ Patients generally a c c e p t simple tests such as total s e r u m cholesterol and are familiar w i t h Pap tests. They also value immunization, although a minority will refuse vaccination declaring "it always gives m e the flu!" or because they harbor m e m o r i e s of the swine flu paralysis. Patients, like physicians, are less a m e n a b l e to advice to change diets or revise long-term habits. Although such counseling can b e t r o u b l e s o m e for b o t h parties, 12 it may be r e n d e r e d m o r e palatable by explaining a direct c o n n e c t i o n to their symptoms. A rising level of p u b l i c awareness, m e d i a coverage a b o u t disease detection in p u b l i c figures, and physician modeling of healthful lifestyles should enhance patient receptivity. Patients deserve c o n c e r n and c o n t i n u e d efforts to p r o l o n g and enhance their lives, w h e t h e r they act on the advice they are given or not. The success or failure of a p a t i e n t - physician relationship d e p e n d s on
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more than following advice. To confront noncompliance frequently leads to a n e w level of understanding b e t w e e n patient and physician.
THE NATURE OF PHYSICIAN TRAINING AND PRACTICE For hundreds of years, physicians were generalists w h o dealt with diet and family conflicts, set bones, and stood by patients in life and death. In the 20th-century United States, medical attention has b e e n devoted almost exclusively to illness management. Prevention responsibility has b e e n largely delegated to public health agencies. Advances in medical science, in-hospital training, specialization among physicians, and illnessfocused insurance systems have all fed this pattern of care. Physicians have increasingly specialized, and as a result only one-third of practitioners n o w provide primary care. In a provocative book, D e a r Doctor: A P e r s o n a l L e t t e r to a P h y s i c i a n , Charles Odegaard, a p r o m i n e n t American educator and historian, expresses c o n c e r n that physicians have lost sight of their h u m a n e function. 13 In casting our lot with science we are in danger of creating a gap b e t w e e n our patients' needs and their expectations. People feel that we d o n ' t listen e n o u g h to their words; we are so focused on their insides that w e don't see their outside world. Dr. Odegaard describes the o r t h o d o x medical establishment, intensively trained in the biomedical model, as lacking awareness about what is happening in man's larger experience. Unfortunately, there is evidence that residency training itself may hinder a more balanced approach. In a recent study of interns' attitudes and relationships with patients during their first year of training, many lost their early p e r c e p t i o n of their role as counselor and advocate. 14 Physicians pride themselves on basing clinical decisions on a pathophysiologic rationale, keeping up to date, and applying proven innovations. One reason given for the failure of physicians to perform more preventive care is the conflicting advice they receive about worthwhile actions, target age groups, or test frequencies. This excuse is no longer tenable with the release o f the U.S. Preventive Service Task Force report, G u i d e to Clinical P r e v e n t i v e Services. t5 It provides clinicians with authoritative recommendations about what preventive care is appropriate and why, based u p o n carefully analyzed studies. The guide discards outdated "head-to-toe" annual checkups and u n p r o v e n maneuvers with unjustified costs or risks.
THE STATE OF THE ART IN PREVENTION Physicians are challenged either to accept personal responsibility to perform preventive services or to refer their patients to appropriate services. Even busy practitioners can manage convenient screening activi-
ties such as b l o o d pressure measurement, cancer screening, or cholesterol tests and make brief inquiries about alcohol, tobacco, or seat belt use. Every primary care physician needs to allocate two or three minutes of each patient visit to talking about prevention. Office nurses should be given a standard protocol for performing immunization and asking questions about previous preventive care. For time-consuming health counseling activities, patients should be referred to low-cost nonprofit programs or commercial organizations.
External Forces External forces transforming U.S. c o n t e m p o r a r y medicine threaten to generate or intensify a wide range of conflicts o f interest and obligation. 8, ~6 The traditional relationship b e t w e e n doctor and patient has b e e n distorted by the introduction of insurance payers, c o n c e r n about rising medical expenses, n e w forms of medical organization, and liability and the threat o f legal suits. Cost C o n t a i n m e n t . Physicians increasingly either practice in large groups w h e r e they are prepaid or reimbursed for specific activities, or are salaried employees of hospitals or health maintenance organizations (HMOs). All emphasize high patient volume. Cost-containment pressures in these settings p r o d u c e conflicts of interest and divided loyalties for the physician. Unless physicians are aware of this shift in the balance of patient care, they will be implementing services selected for the benefit of the organization rather than the patient. To h o n o r their obligation as patient advocates, proponents n e e d to participate in negotiations to include effective p r e v e n t i o n activities. D e f e n s i v e M e d i c i n e - - W i l l I Be Sued?. Physician apprehension about litigation prompts inappropriate or excessive test or p r o c e d u r e ordering, socalled "defensive m e d i c i n e . " This behavior uses valuable health resources. To the extent that defensive medicine diverts attention and resources away from preventive services, preventive care will suffer. In a contract type of practice, a physician must do what is required and specified or be penalized for doing too little or too much. Some hospitals are unwilling to establish a prevention policy or to insert prevention guidelines in the chart, out of concern that they c o u l d be used as evidence that physicians failed to provide "standard care." The recent rash of suits by patients, whose cancers went u n d e t e c t e d until symptomatic, against physicians or even tobacco companies and alcohol distilleries suggests that public expectations have gone beyond illness care. These forces may act to encourage provision of certain preventive activities while excluding others. Given the desirability o f efficient use o f medical resources and the inevitability of monitoring n e w standards of care, it w o u l d seem p r u d e n t for physicians to b e c o m e more involved in the development of standards and the process of quality assurance.
JOURNALOFGENERALINTERNALMEDICINE,Volume~ (September/OctoberSupplement), 1990
CHALLENGES FOR THE MEDICAL PROFESSION As part of their professional duty, physicians have an obligation to inform the p u b l i c about a p p r o p r i a t e preventive activities, their risks and benefits, and w h e r e to obtain services. The G u i d e to C l i n i c a l Prev e n t i v e Services t5 makes it possible for clinicians to p e r f o r m screening and counseling activities based on evidence rather than habit. It provides a standard for quality assurance. Physicians n e e d to use the information to confront colleagues w h o d o n ' t h e e d standards. Those physicians interested in p r o m o t i n g preventive care n e e d to infiltrate the p o w e r structures of o u r health care institutions, HMOs, hospitals, g r o u p practices, and medical schools. Preventive services are less available to minorities, the elderly, the poor, and those in isolated c o m m u n i t i e s . Preventive care services, like the lifeboats of the Titanic, 17 go tO the privileged. Influence is n e e d e d at the level w h e r e resource allocation decisions are made to reinforce the d o c t o r - patient relationship and to initiate favorable r e i m b u r s e m e n t schedules. There is a role for physicians to go b e y o n d direct patient care to counsel in schools (e.g., Doctors O u g h t to Care, DOC), h e l p w i t h p u b l i c education, or s u p p o r t smoke-free regulations.
CHALLENGES FOR THE PHYSICIAN As legal, e c o n o m i c , and organizational forces act to change the landscape in w h i c h patient care is given, physicians' control of preventive services may b e red u c e d to a set of services stipulated on paper, no m o r e and no less. In this environment, physicians n e e d to e x a m i n e their values and beliefs, their inner selves, though this is not w i t h o u t risk. Physicians n e e d to ask w h a t kind of p e o p l e they w e r e m e a n t to be and therefore, what kind of m e d i c i n e they will practice. This obligation draws attention to the d o c t o r - p a t i e n t relationship, to social justice, and to the forces shaping resource allocation. Although external forces are creating pressure to m o v e toward contractual relationships, they will impoverish professional relationships, tending to prod u c e a physician w h o will not go the " s e c o n d m i l e " with his patient. Physicians strive to maintain a balance b e t w e e n a l t r u i s m - - c o n c e r n for the patient's welfare m a n d attending to their o w n self-interest. Current insurance schedules offer little incentive for health counseling and disease-screening efforts. Instead, they induce physicians to s p e n d time in m o r e lucrative areas. Devoting time and effort to p r e v e n t i o n in pursuing the patient's welfare u n d e r these circumstances is likely to p r o d u c e a continuing tension b e t w e e n physician self-interest and altruism towards patients, w h a t Jonsen terms a " p r o f o u n d moral paradox. ' ' i s The physician's character, sensitivity, and generosity in seeking a patient's best interests are at stake. In a m o v i n g essay,
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" T h e Secret of Patient Care. ''19 Dale Matthews challenges us to b e c o m e m o r e h u m a n in our patient relationships because w h e n w e take risks w e forge a closer bond. He asks w h e t h e r w e want our epitaphs to read " H e was an efficient and cost-effective user of medical t e c h n o l o g y and scarce r e s o u r c e s " or to ask "Was he loved? Did he love?" Although our medical system is passing through a diffficult and confusing time, physicians m u s t not b l a m e failures in p r e v e n t i o n on outside factors. Physicians need to be m o r e honest about the continuing opportunities to give preventive services to patients, regardless of the practice environment. If p r e v e n t i o n is going to b e done, it will b e d o n e by p r i m a r y care physicians w h o are m o r e c o m m i t t e d to the care of the w h o l e person, not just to treating a particular illness or disease syndrome. Primary care is p r i m a r y in the sense that the patient's welfare is first and foremost, as well as p r i m a r y in the sense of entry into the medical system. W h e n all is said and done, it is still only m e and m y patient in the consultation r o o m . He wants to k n o w w h a t I recommend. I care a b o u t w h a t h a p p e n s to him.
REFERENCES 1. Winkenwerder W, Ball JR. Transformation of American health care. The role of the medical profession. N Engl J Med. 1988;318:317-9. 2. Seigler M. The progression of medicine: from physician paternalism to patient autonomy to bureaucratic parsimony. Arch Intern Med. 1985;145:713-5. 3. Belcher DW, Berg AO, Inui TS. Practical approaches to providing better preventive care: are physicians a problem or a solution? AmJ Prey Med. 1988;4 (4 suppl):27-48. 4. Eisenberg JM. Doctors' decisions and the cost of medical care. Ann Arbor, MI. Health Administration Press, 1986. 5. Ad Hoc Committee on Medical Ethics, American College of Physicians. American College of Physicians ethics manual, part 1. Ann Intern Med. 1984;101:129-37. 6. Loewy EH. Duties, fears and physicians. Soc Sci Med. 1986;22:1363-6. 7. Chren MM, Landefeld CS, Murray TH. Doctors, drug companies, and gifts. IAMA. 1989;262:3448-51. 8. Murray TH. Divided loyalties for physicians: social context and moral problems. Soc Sci Med. 1986;23:827-32. 9. Siegler M. A right to health care: ambiguity, professional responsibility, and patient liberty. J Med Philos. 1979;4:148-57. 10. May WF. Code, covenant, contract, or philanthropy. Hastings Center Rep. 1975;5:29-38. 11. Katz J. The silent world of doctor and patient. New York: Free Press, 1984. 12. Freeman SH. Health promotion talk in family practice encounters. Soc Sci Med. 1987;961-6. 13. Odegaard CE. Dear doctor. A personal letter to a physician. Menlo Park, CA: The HenryJ. Kaiser Family Foundation, 1986. 14. Sparr LF, Gordon GH, Hickam DH, Girard DE. The d o c t o r patient relationship during medical internship: the evolution of dissatisfaction. Soc Sci Med. 1988;26:1095-101. 15. U.S. Preventive Services Task Force. Guideto clinical preventive services: an assessment of the effectivenessof 169 interventiol~s. Baltimore: Williams and Wilkins, 1989. 16. Smith HL. Medical ethics in the primary care setting- Soc Sci Med. 1987;25:705-9. 17. Hall W. Social class and survival on the S.S. Titanic. Soc Sci Med. 1986;687-90. 18. Jonsen AR. Watching the doctor. N Engl J Med. 1983; 308:1531-5. 19. Matthews DA. The secret of patient care. SGIM Newsletter. 1989;12:1 ;6;8-9.
skill in preventive care, primary care providers do accept a n obligation to p r o v i d e c o m p r e h e n s i v e care, i n c l u d i n g p r e v e n t i o n . This p a p e r e x a m i n e s the ethical basis f o r the idea o f obligation. E x t e r n a l pressures, legag economic, a n d o r g a n i z a t i o n a ~ a r e affecting the p h y s i c i a n - p a t i e n t relationship in ways t h a t e n c o u r a g e a c o n t r a c t m o d e o f medical p r a c t i c e a n d limit physicians" ability to p r o v i d e p r e v e n t i v e care. As a p r o f e s s i o n , medicine needs to s p e a k f o r the health needs o f the public. As practitioners, physic i a n s n e e d to seek the weO'are o f t h e i r patients. Key words: prevention,, obligation,, p h y s i c i a n - p a t i e n t relationship. J GEN INTERN MED 1990;5(suppl):S104- $107.
T o UNDERSTANDa physician's obligation to p r o v i d e prevention services, the historic relationship b e t w e e n d o c t o r and patient in its ethical dimension n e e d s to be examined. What do physicians owe their patients and society?~, 2 Are physicians e m p l o y e e s of a system, private contractors, or professionals like architects or lawyers, or are physicians part of a long line of healers w i t h a priestly function, e v e n w i t h o u t a theology? In preventive care, one must look b e y o n d science and technology to the heart of the interaction o f physician and patient.
PHYSICIANS' PREVENTION BEHAVIOR A recent five-year randomized trial involved 1,200 male Seattle VA Medical Center outpatients to test w h e t h e r activating patients or motivating physicians w o u l d increase preventive services. 3 This trial tested three innovations: a chart flowsheet; patient e d u c a t i o n w i t h a mini-record; and a health surveillance clinic. Seattle VA Medical Center physicians agreed in baseline surveys that the small set of r e c o m m e n d e d a c t i v i t i e s - - b l o o d pressure m e a s u r e m e n t , fecal occult b l o o d testing, cholesterol screening, influenza vaccina-
Received from the Division of General Internal Medicine, University of Washington, and the Veterans Administration Medical Center, Seattle, Washington. Presented at the conference, Frontiers in Disease Prevention, Tile Johns Hopkins University, June 5 - 6, 1989. Supported in part by the Department of Veteran Affairs. Address correspondence to Dr. Belcher: General Internal Medicine Clinic (111M), Seattle VAMC, 1660 Columbian Way South, Seattle, WA 98108. Reprints are not available.
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tion, and inquiries a b o u t alcohol and t o b a c c o u s e - w e r e appropriate. However, chart audits s h o w e d that only 2 0 - 25% of patients received these services. The one e x c e p t i o n was b l o o d pressure checks, p e r f o r m e d chiefly b y nurses at patient check-in. W h e n apprised of this gap b e t w e e n intention and p e r f o r m a n c e , physicians reiterated their s u p p o r t for the c o n c e p t of preventive care and the i m p o r t a n c e of e x p a n d i n g prevention. Each patient in one e x p e r i m e n t a l g r o u p r e c e i v e d an individualized list of r e c o m m e n d e d p r e v e n t i o n activities and was asked to s h o w it to his doctor at the n e x t visit. Virtually no patient m a d e use of his or her guidelines. W h e n asked why, m a n y stated that " m y doctor should k n o w w h a t is best for m e " or "this sort of thing is the doctor's job." Many patients are not yet ready to assume an assertive role to obtain preventive care, so doctors still n e e d to take the initiative. A t e c h n i q u e designed to trigger physician response was used w i t h o n e trial group. A flowsheet w i t h checkoff b o x e s for each of the r e c o m m e n d e d p r o c e d u r e s was inserted on the inside front c o v e r of a patient's chart. Charts w e r e audited annually for five years to see w h e t h e r the flowsheet was used or w h e t h e r the physician p r o v i d e d any of the r e c o m m e n d e d activities. Results of this trial w e r e disappointing. E x p e r i e n c e d physicians, all in salaried positions, c o n t i n u e d to p e r f o r m at their baseline levels, despite e x p o s u r e to recent prevention information and central administration exhortations to do more. At first it was assumed that the l o w rates w e r e cause by specialists w h o focus on limited p r o b l e m s . While medical subspecialists p e r f o r m e d certain preventive activities relevant to their fields, they often v i e w e d additional efforts as b e i n g outside their service domains. Psychiatrists stated that they never p e r f o r m e d physical examinations at visits and wished s o m e o n e else w o u l d p r o v i d e p r e v e n t i v e care. Surgeons n o t e d that their i n v o l v e m e n t w i t h patients was typically short-term and that they w e r e highly trained specialists w h o did not do p r i m a r y care. Unexpectedly, the general internists also failed to e x p a n d preventive care over the entire five years. The level of services r e m a i n e d stuck at the baseline prevention level. In D o c t o r s ' D e c i s i o n s a n d t h e C o s t o f M e d i c a l Care, John Eisenberg describes h o w hard it is to change physicians' practice behavior. 4 Several papers presented at the Montreal s y m p o s i u m on i m p l e m e n t i n g preventive services 3 suggest that no a m o u n t of consensus building, training, feedback, or s u p p o r t resources is likely to w o r k unless the physician is motivated to act.
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ETHICAL FRAMEWORK FOR PHYSICIAN'S OBLIGATIONS TO PATIENTS Consideration of a physician's obligation to patients goes to the heart and p u r p o s e of the medical profession, its role in society and history, 5 and that intimate and mysterious b o n d b e t w e e n patient and physician. Physicians are t e m p t e d to o v e r l o o k the ethical, philosophical, and religious aspects of their responsibility, as individuals and as a profession. Health care professionals n e e d to ask, "Are we thinking of our patients? Do w e really put o u r patients' welfare first?"6, 7 An obligation can be variously defined as a promise, a duty, a contract, or a responsibility to p u r s u e the patient's interest by following a course of action that is shaped b y society, knowledge, law, or conscience. A physician's relationship to patients can be described as fiduciary, because doctors are e x p e c t e d to act in the best interest of the patient. ~ The H i p p o c r a t i c oath speaks of entering into a p h y s i c i a n - p a t i e n t relationship " f o r the good of the sick to the utmost of m y p o w e r s . " In classical times, the relationship b e t w e e n the physician and the patient was s u r r o u n d e d b y spiritual significance and obligation. Great physicians of the middle ages, Christian, Jewish, and Islamic, provide e x a m p l e s of those w h o offered skillful and sacrificial care. St. Bartholomew's in London, f o u n d e d in the 12th century, has a h i s t o r y o f c a r i n g for lepers, the poor, and those with the plague. Just to n a m e m a n y American h o s p i t a l s - - s u c h as C o l u m b i a Presbyterian, St. Luke's, Providence, Mount Sinai, Beth Israel, C h a r i t y - - reminds us that they w e r e founded b y p e o p l e motivated by religious compassion.
THE PHYSICIAN-PATIENT RELATIONSHIP: COVENANT OR CONTRACT? What is the nature of the relationship b e t w e e n physicians and patients? Is it a covenantal relationship or a legal contract? In what sense is a physician different from a building contractor? Mark Siegler points out that the traditional d o c t o r - p a t i e n t relationship is a covenantal m o d e l based on promise-keeping, fidelity, indebtedness to society, and justice, not a contractual model.9 Covenants involve a c o m m i t m e n t to k e e p working, not to do only the m i n i m u m , or w h a t is c o n v e n i e n t or easy. I m p l i c i t in the covenant relationship is a gift, a promise, or a special relationship rather than a p a y m e n t for a specific job. The gift conveys a sense of special obligation. God p r o m i s e d a land to his chosen p e o p l e and invited t h e m to be o b e d i e n t to his law. Marriage vows as a covenant r e p r e s e n t a lifelong c o m m i t m e n t , in sickness or in health, in riches or in poverty. Much of the m o d e r n practice and e c o n o m i c s of m e d i c i n e is moving toward a contractual model. A contract has legal connotations with its stipulation of actions required of b o t h parties, boundaries of work, and penalties for failure of either party to perform. The
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contract m o d e l encourages litigation and impoverishes the p a t i e n t - p h y s i c i a n relationship. Moreover, patients lack the technical k n o w l e d g e to make t h e m an equal party to a medical contract. 9
PHYSICIAN INDEBTEDNESS TO SOCIETY AND THE PATIENT William May reminds us in his illuminating article, "Code, c o v e n a n t , contract, or p h i l a n t b r o p y , " that as physicians we o w e an incalculable d e b t b o t h to patients and to s o c i e t y ) ° Physicians are blessed with immense privileges and power, as well as considerable material reward. 6 Doctors do well to consider the gift of trust received in patient relationships. Such an appreciation can motivate and sustain us in caring for the patient " t o the utmost of our p o w e r s . " We have only to recall o u r earliest patients to recognize our indebtedness and to better a p p r e c i a t e o u r title " p r a c t i t i o n e r . " I especially r e m e m b e r Mrs. Mapp, m o t h e r of ten children, w h o m I visited as a second-year medical student in her "South Philly" h o m e or joined in her visits to the University Hospital pediatrics clinic. She was most polite and respectful to an u n m a r r i e d intern's advice about a feeding schedule for her infant, but w h e n he b e n t to write, she turned and gave m e a large wink. It was m y first observation of the p o w e r of patients in a m b u l a t o r y care and h o w important it is to a c k n o w l e d g e their c o m p e t e n c e and preferences.
PATIENT ROLE AND EXPECTATIONS The lay person relies on the physician's expert fund of k n o w l e d g e and experience, w h i c h is largely one-sided. He e x p e c t s doctors to show concern, to be of practical service, and to provide the same quality of care they w o u l d render to a colleague or to a relative. W h e t h e r patients expect, w e l c o m e , or act u p o n preventive care advice is another matter. Physicians are partly to blame, since they have only recently b e e n willing to enter into a dialogue w i t h their patients, x~ Patients generally a c c e p t simple tests such as total s e r u m cholesterol and are familiar w i t h Pap tests. They also value immunization, although a minority will refuse vaccination declaring "it always gives m e the flu!" or because they harbor m e m o r i e s of the swine flu paralysis. Patients, like physicians, are less a m e n a b l e to advice to change diets or revise long-term habits. Although such counseling can b e t r o u b l e s o m e for b o t h parties, 12 it may be r e n d e r e d m o r e palatable by explaining a direct c o n n e c t i o n to their symptoms. A rising level of p u b l i c awareness, m e d i a coverage a b o u t disease detection in p u b l i c figures, and physician modeling of healthful lifestyles should enhance patient receptivity. Patients deserve c o n c e r n and c o n t i n u e d efforts to p r o l o n g and enhance their lives, w h e t h e r they act on the advice they are given or not. The success or failure of a p a t i e n t - physician relationship d e p e n d s on
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more than following advice. To confront noncompliance frequently leads to a n e w level of understanding b e t w e e n patient and physician.
THE NATURE OF PHYSICIAN TRAINING AND PRACTICE For hundreds of years, physicians were generalists w h o dealt with diet and family conflicts, set bones, and stood by patients in life and death. In the 20th-century United States, medical attention has b e e n devoted almost exclusively to illness management. Prevention responsibility has b e e n largely delegated to public health agencies. Advances in medical science, in-hospital training, specialization among physicians, and illnessfocused insurance systems have all fed this pattern of care. Physicians have increasingly specialized, and as a result only one-third of practitioners n o w provide primary care. In a provocative book, D e a r Doctor: A P e r s o n a l L e t t e r to a P h y s i c i a n , Charles Odegaard, a p r o m i n e n t American educator and historian, expresses c o n c e r n that physicians have lost sight of their h u m a n e function. 13 In casting our lot with science we are in danger of creating a gap b e t w e e n our patients' needs and their expectations. People feel that we d o n ' t listen e n o u g h to their words; we are so focused on their insides that w e don't see their outside world. Dr. Odegaard describes the o r t h o d o x medical establishment, intensively trained in the biomedical model, as lacking awareness about what is happening in man's larger experience. Unfortunately, there is evidence that residency training itself may hinder a more balanced approach. In a recent study of interns' attitudes and relationships with patients during their first year of training, many lost their early p e r c e p t i o n of their role as counselor and advocate. 14 Physicians pride themselves on basing clinical decisions on a pathophysiologic rationale, keeping up to date, and applying proven innovations. One reason given for the failure of physicians to perform more preventive care is the conflicting advice they receive about worthwhile actions, target age groups, or test frequencies. This excuse is no longer tenable with the release o f the U.S. Preventive Service Task Force report, G u i d e to Clinical P r e v e n t i v e Services. t5 It provides clinicians with authoritative recommendations about what preventive care is appropriate and why, based u p o n carefully analyzed studies. The guide discards outdated "head-to-toe" annual checkups and u n p r o v e n maneuvers with unjustified costs or risks.
THE STATE OF THE ART IN PREVENTION Physicians are challenged either to accept personal responsibility to perform preventive services or to refer their patients to appropriate services. Even busy practitioners can manage convenient screening activi-
ties such as b l o o d pressure measurement, cancer screening, or cholesterol tests and make brief inquiries about alcohol, tobacco, or seat belt use. Every primary care physician needs to allocate two or three minutes of each patient visit to talking about prevention. Office nurses should be given a standard protocol for performing immunization and asking questions about previous preventive care. For time-consuming health counseling activities, patients should be referred to low-cost nonprofit programs or commercial organizations.
External Forces External forces transforming U.S. c o n t e m p o r a r y medicine threaten to generate or intensify a wide range of conflicts o f interest and obligation. 8, ~6 The traditional relationship b e t w e e n doctor and patient has b e e n distorted by the introduction of insurance payers, c o n c e r n about rising medical expenses, n e w forms of medical organization, and liability and the threat o f legal suits. Cost C o n t a i n m e n t . Physicians increasingly either practice in large groups w h e r e they are prepaid or reimbursed for specific activities, or are salaried employees of hospitals or health maintenance organizations (HMOs). All emphasize high patient volume. Cost-containment pressures in these settings p r o d u c e conflicts of interest and divided loyalties for the physician. Unless physicians are aware of this shift in the balance of patient care, they will be implementing services selected for the benefit of the organization rather than the patient. To h o n o r their obligation as patient advocates, proponents n e e d to participate in negotiations to include effective p r e v e n t i o n activities. D e f e n s i v e M e d i c i n e - - W i l l I Be Sued?. Physician apprehension about litigation prompts inappropriate or excessive test or p r o c e d u r e ordering, socalled "defensive m e d i c i n e . " This behavior uses valuable health resources. To the extent that defensive medicine diverts attention and resources away from preventive services, preventive care will suffer. In a contract type of practice, a physician must do what is required and specified or be penalized for doing too little or too much. Some hospitals are unwilling to establish a prevention policy or to insert prevention guidelines in the chart, out of concern that they c o u l d be used as evidence that physicians failed to provide "standard care." The recent rash of suits by patients, whose cancers went u n d e t e c t e d until symptomatic, against physicians or even tobacco companies and alcohol distilleries suggests that public expectations have gone beyond illness care. These forces may act to encourage provision of certain preventive activities while excluding others. Given the desirability o f efficient use o f medical resources and the inevitability of monitoring n e w standards of care, it w o u l d seem p r u d e n t for physicians to b e c o m e more involved in the development of standards and the process of quality assurance.
JOURNALOFGENERALINTERNALMEDICINE,Volume~ (September/OctoberSupplement), 1990
CHALLENGES FOR THE MEDICAL PROFESSION As part of their professional duty, physicians have an obligation to inform the p u b l i c about a p p r o p r i a t e preventive activities, their risks and benefits, and w h e r e to obtain services. The G u i d e to C l i n i c a l Prev e n t i v e Services t5 makes it possible for clinicians to p e r f o r m screening and counseling activities based on evidence rather than habit. It provides a standard for quality assurance. Physicians n e e d to use the information to confront colleagues w h o d o n ' t h e e d standards. Those physicians interested in p r o m o t i n g preventive care n e e d to infiltrate the p o w e r structures of o u r health care institutions, HMOs, hospitals, g r o u p practices, and medical schools. Preventive services are less available to minorities, the elderly, the poor, and those in isolated c o m m u n i t i e s . Preventive care services, like the lifeboats of the Titanic, 17 go tO the privileged. Influence is n e e d e d at the level w h e r e resource allocation decisions are made to reinforce the d o c t o r - patient relationship and to initiate favorable r e i m b u r s e m e n t schedules. There is a role for physicians to go b e y o n d direct patient care to counsel in schools (e.g., Doctors O u g h t to Care, DOC), h e l p w i t h p u b l i c education, or s u p p o r t smoke-free regulations.
CHALLENGES FOR THE PHYSICIAN As legal, e c o n o m i c , and organizational forces act to change the landscape in w h i c h patient care is given, physicians' control of preventive services may b e red u c e d to a set of services stipulated on paper, no m o r e and no less. In this environment, physicians n e e d to e x a m i n e their values and beliefs, their inner selves, though this is not w i t h o u t risk. Physicians n e e d to ask w h a t kind of p e o p l e they w e r e m e a n t to be and therefore, what kind of m e d i c i n e they will practice. This obligation draws attention to the d o c t o r - p a t i e n t relationship, to social justice, and to the forces shaping resource allocation. Although external forces are creating pressure to m o v e toward contractual relationships, they will impoverish professional relationships, tending to prod u c e a physician w h o will not go the " s e c o n d m i l e " with his patient. Physicians strive to maintain a balance b e t w e e n a l t r u i s m - - c o n c e r n for the patient's welfare m a n d attending to their o w n self-interest. Current insurance schedules offer little incentive for health counseling and disease-screening efforts. Instead, they induce physicians to s p e n d time in m o r e lucrative areas. Devoting time and effort to p r e v e n t i o n in pursuing the patient's welfare u n d e r these circumstances is likely to p r o d u c e a continuing tension b e t w e e n physician self-interest and altruism towards patients, w h a t Jonsen terms a " p r o f o u n d moral paradox. ' ' i s The physician's character, sensitivity, and generosity in seeking a patient's best interests are at stake. In a m o v i n g essay,
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" T h e Secret of Patient Care. ''19 Dale Matthews challenges us to b e c o m e m o r e h u m a n in our patient relationships because w h e n w e take risks w e forge a closer bond. He asks w h e t h e r w e want our epitaphs to read " H e was an efficient and cost-effective user of medical t e c h n o l o g y and scarce r e s o u r c e s " or to ask "Was he loved? Did he love?" Although our medical system is passing through a diffficult and confusing time, physicians m u s t not b l a m e failures in p r e v e n t i o n on outside factors. Physicians need to be m o r e honest about the continuing opportunities to give preventive services to patients, regardless of the practice environment. If p r e v e n t i o n is going to b e done, it will b e d o n e by p r i m a r y care physicians w h o are m o r e c o m m i t t e d to the care of the w h o l e person, not just to treating a particular illness or disease syndrome. Primary care is p r i m a r y in the sense that the patient's welfare is first and foremost, as well as p r i m a r y in the sense of entry into the medical system. W h e n all is said and done, it is still only m e and m y patient in the consultation r o o m . He wants to k n o w w h a t I recommend. I care a b o u t w h a t h a p p e n s to him.
REFERENCES 1. Winkenwerder W, Ball JR. Transformation of American health care. The role of the medical profession. N Engl J Med. 1988;318:317-9. 2. Seigler M. The progression of medicine: from physician paternalism to patient autonomy to bureaucratic parsimony. Arch Intern Med. 1985;145:713-5. 3. Belcher DW, Berg AO, Inui TS. Practical approaches to providing better preventive care: are physicians a problem or a solution? AmJ Prey Med. 1988;4 (4 suppl):27-48. 4. Eisenberg JM. Doctors' decisions and the cost of medical care. Ann Arbor, MI. Health Administration Press, 1986. 5. Ad Hoc Committee on Medical Ethics, American College of Physicians. American College of Physicians ethics manual, part 1. Ann Intern Med. 1984;101:129-37. 6. Loewy EH. Duties, fears and physicians. Soc Sci Med. 1986;22:1363-6. 7. Chren MM, Landefeld CS, Murray TH. Doctors, drug companies, and gifts. IAMA. 1989;262:3448-51. 8. Murray TH. Divided loyalties for physicians: social context and moral problems. Soc Sci Med. 1986;23:827-32. 9. Siegler M. A right to health care: ambiguity, professional responsibility, and patient liberty. J Med Philos. 1979;4:148-57. 10. May WF. Code, covenant, contract, or philanthropy. Hastings Center Rep. 1975;5:29-38. 11. Katz J. The silent world of doctor and patient. New York: Free Press, 1984. 12. Freeman SH. Health promotion talk in family practice encounters. Soc Sci Med. 1987;961-6. 13. Odegaard CE. Dear doctor. A personal letter to a physician. Menlo Park, CA: The HenryJ. Kaiser Family Foundation, 1986. 14. Sparr LF, Gordon GH, Hickam DH, Girard DE. The d o c t o r patient relationship during medical internship: the evolution of dissatisfaction. Soc Sci Med. 1988;26:1095-101. 15. U.S. Preventive Services Task Force. Guideto clinical preventive services: an assessment of the effectivenessof 169 interventiol~s. Baltimore: Williams and Wilkins, 1989. 16. Smith HL. Medical ethics in the primary care setting- Soc Sci Med. 1987;25:705-9. 17. Hall W. Social class and survival on the S.S. Titanic. Soc Sci Med. 1986;687-90. 18. Jonsen AR. Watching the doctor. N Engl J Med. 1983; 308:1531-5. 19. Matthews DA. The secret of patient care. SGIM Newsletter. 1989;12:1 ;6;8-9.
