The lead story in today’s New York Times brings to the fore an emerging question in medicine: when providing care and offering advice, should a physician think only of the patient in front of her, or does she have an obligation to balance the needs of the individual patient with the broader needs of society?
I strongly agree with Harvard neurologist Marty Samuels, who told the NYT, “There should be forces in society who should be concerned about the budget, about how many M.R.I.s we do, but they shouldn’t be functioning simultaneously as doctors."
Added the Times, “Samuels said doctors risked losing the trust of patients if they told patients, ‘I’m not going to do what I think is best for you because I think it’s bad for the health care budget in Massachusetts.’”
It seems absolutely essential to me that when a patient receives advice from a physician, the patient knows that this reflects the best medical advice from the doctor, and not some murky weighing of whether the patient is more deserving than society.
This prioritization of the individual patient is consistent with a desire for cost transparency (cost can matter a lot to patients), and with physicians understanding and being able to explain the costs and potential benefits of a range of treatment options (to the extent multiple options are available — sadly, this often is not the case). (Addendum: as Ashish Jha more eloquently phrased this point, “Should MDs consider costs as it affects their patients? Yes! How about how $ affect society? Not clear.” [In the case of the treating physician, I'm arguing "no."])
The foundation of the physician-patient relationship, the bedrock of care, is, should, and must be the unshakable trust the patient has that his doctor will do what’s best for him. Once this faith is breached, it may never be restored, to the permanent detriment of both patients and the profession of medicine.
At that point, physicians will truly transform into the bureaucrats and bean counters they’ve struggled so valiantly not to become.
- – - -
I’ve discussed a number of key issues related to patients and populations extensively before, in three related contexts: (1) Should clinicians focus on patients or populations? (2) End of life (or not) decisions; (3) Balancing patient and population benefit in medical research. See related links below:
Should Doctors Focus On Patients Or Populations:
On End Of Life (or not) Decisions:
“’But Doctor, I Want To Live!’ The Other Side Of The ‘Dignified Death’ Debate”
Balancing Patient and Population Benefit In Medical Research: