PRESERVING THE PHYSICIAN-PATIENT RELATIONSHIP IN THE ERA OF MANAGED CARE
PRESERVING THE PHYSICIAN-PATIENT RELATIONSHIP IN THE ERA OF MANAGED CARE
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DOI：
10.1001/jama.273.4.323
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发表时间：
1995-01-25
影响因子：
120.7
通讯作者：
DUBLER, NN
中科院分区：
文献类型：
--
作者：
EMANUEL, EJ;DUBLER, NN
即使没有全面的医疗保健改革立法，美国的医疗保健系统也正在发生重大变化。也许最重要的变化是管理式医疗的扩大，价格竞争激烈。对这一变化的主要关注之一是管理式医疗对医患关系的影响。为评价医疗改革的效果提供规范性标准，需要一个理想的医患关系概念。这个理想可以用六个C来概括：选择、能力、沟通、同情、连续性和（无）利益冲突。对于3700万没有保险的美国人来说，实现理想的医患关系的可能性很小，因为他们缺乏对实践环境和医生的选择，在匆忙的气氛中接受护理，破坏了沟通和同情，并且没有护理的连续性。虽然许多投保的美国人可能认为他们有一个理想的医患关系，但这种关系受到缺乏定期能力评估，破坏良好沟通的经济激励以及利益冲突持续存在的威胁。转向管理式护理可能会改善实践环境的选择，特别是在该国目前缺乏管理式护理的部分地区;增加预防服务的选择;使质量评估更加常规化;并通过更多地使用初级保健医生和非医生提供者来改善沟通。然而，管理式护理的扩展和实施重大成本控制有可能破坏理想的医患关系的各个方面。选择可能受到雇主和管理式保健对医生的选择的限制;质量指标不佳可能破坏对能力的评估;生产力要求可能消除沟通所需的时间;为确保最低费用而从一个管理式保健计划改为另一个管理式保健计划可能严重破坏保健的连续性;使用薪酬方案奖励不使用医疗服务的医生可能会增加利益冲突。
Even without comprehensive health care reform legislation, the US health care system is undergoing significant changes. Probably the most important change is the expansion of managed care with significant price competition. One of the major concerns about this change is the effect of managed care on the physician-patient retationship. To provide a normative standard for evaluating the effect of changes, we need an ideal conception of the physician-patient relationship. This ideal can be summarized by six C's: choice, competence, communication, compassion, continuity, and (no) conflict of interest. For the 37 million uninsured Americans there is little chance of realizing the ideal physician-patient relationship, since they lack the choice of practice setting and physician, receive care in a rushed atmosphere that undermines communication and compassion, and have no continuity of care. While many insured Americans may believe they have an ideal physician-patient relationship, the relationship is threatened by lack of a regular assessment of competence, by financial incentives that undermine good communication, and by the persistence of conflict of interest. The shift to managed care may improve the choice of practice settings, especially in sections of the country that currently lack managed care; increase choice of preventive services; make quality assessments more routine; and improve communication by making greater use of primary care physicians and nonphysician providers. However, the expansion of managed care and the imposition of significant cost control have the potential to undermine all aspects of the ideal physician-patient relationship. Choice could be restricted by employers and by managed care selection of physicians; poor quality indicators could undermine assessments of competence; productivity requirements could eliminate time necessary for communication; changing from one to another managed care plan to secure the lowest costs could produce significant disruption in continuity of care; and use of salary schemes that reward physicians for not using medical services could increase conflict of interest.