What are YOUR responsibilities? Dr. K gives his view
Peter Katsufrakis, M.D., M.B.A.

I suspect that most people coming to medical school do so to learn how to care for patients.  The majority of time spent in school focuses on just that goal: becoming a skilled, empathic, excellent clinician.  However, students seem increasingly aware of the multiple roles physicians play in influencing our nation’s health care.  At the request of the Chief Complaint editorial staff, I am happy to offer my thoughts on the social & political responsibilities of future physicians.

Historically, physicians enjoyed almost unquestioned autonomy and authority in matters of health.  Most physicians envisioned their primary responsibility and realm of action as being their one-on-one interaction with patients.  However, we are often unable to maximize our patients’ health if we limit our actions only to direct patient care.  Increasingly, as physicians we must be aware of the political and social milieu in which we practice medicine, and engage in the controversies and opportunities that arise.

As an example, we can look to past funding for health care.  Decades ago, medical care was unfettered by concerns about utilization costs.  One good effect of this environment was that physicians could optimize each patient’s care according to the physician’s (and patient’s) view of optimal health.  However, bad effects included excessive costs without proven benefit, and suboptimal oversight of marginal or bad physicians.  Rising costs created a ripe environment for “Medicine as a business” as companies formed to manage physicians, and health care.  Sadly, physicians’ voices and values were mostly missing as this transformation took place. 

I believe that the future holds opportunities for physicians to shift priorities in favor of patients, not in disregard for the economic effects of our actions but rather by weighing costs from the perspective of optimal health, and by designing and implementing policies that accurately reflect the informed will of our society. What trends may influence future choices? 

One significant trend is increasing patient autonomy and interest in health.  Seen by some physicians as a threat to physicians’ authority and competence, patient autonomy can be seen as an unfortunate challenge to our knowledge and expertise.  However, I would argue the opposite:  Patients’ involvement in their care has been shown to correlate with improved health outcomes, so it should be encouraged.  Rather than seeing patient questions as an affront to our proficiency, we should encourage patients to learn about health and their diseases, and to discuss their learning and questions with us.

One tool that facilitates patient involvement in health care is information technology.  Medicine has been woefully slow to adopt technology, a fact that is ironic given that healthcare consumes more than 15% of the US gross domestic product and that the stakes are literally life-or-death.In the future, we should anticipate that there will be increasing standardization and universal adoption of the electronic health record (EHR), with immediate point-of-care access to - and transportability of - an individual’s medical record between clinical sites.  The Internet is already used routinely as a source of information (good and bad) for patient education; we may anticipate that home health “ appliances” to monitor blood pressure, glucose, etc. will be tied into physicians’ and/or health care systems’ management tools, transmitting specific patient information and allowing management at home of diseases that would previously have resulted in a trip to the office.

We should also anticipate increasing emphasis on patient outcomes.  Historically, physicians’ accountability for patients was not measured very systematically or reliably.  Increasingly, there is emphasis on patient satisfaction, adherence to proven management protocols, and other measures of health care.  Recognizing that health is often an outcome of a “system” and not solely the doctor’s responsibility, I expect that the future will move toward holding health care systems responsible for a patient’s health.  We may even see the day when a community’s health will be evaluated, as a measure of its physicians’ and its other health care providers’ effectiveness.

This brief review of some of the changes in health care economics is superficial and incomplete, and doesn’t even begin to consider many of the social and political challenges we will face in the future.  What are opportunities for physicians?  Fundamentally, I believe we face the choice either to lead change efforts, or to be a part of a system developed by others who may not share our expertise, values, or perspective.  We can define what constitutes good health, or accept definitions created by others.  I believe physicians also must help society grapple with fundamental questions such as: Is health a “right” or a “benefit”?  How should we decide about allocation of resources to health vs. other areas of need, e.g., education or defense?  How do we answer fundamental ethical and moral questions, e.g., right to life, right to die, etc.?  What are the valued outcomes of health care, and how can we best achieve them?  What is an “acceptable” level of disparity between the wealthiest and the poorest in our society?  Do organizations of physicians advocate for the best interests of society, or the best interests of physicians?  Regardless of how you feel we should answer these questions, I hope you agree that, as physicians, we owe it to our society to participate in the search for answers to these questions.