Genes, Medicine, & Managed Care
To the Editor,
In their thoughtful essay regarding medicine and our genes the authors
highlight the increasing need for physicians to thoughtfully analyze
and address with their patients the implications of new diagnostic
technologies whose findings are most understandable in the language
of probabilities and risk factors rather than certainties and rigid
categories. Unfortunately, all to many managed health care practices
militate against translating these new advances into more effective
and personal health care. For example managed care practices include
the pernicious profiling and economic deselection of those physicians
as reimbursable providers who spend the additional resources to formulate
a probabilistic differential diagnosis and to translate such information
into a meaningful dialog with patients. The end result is that physicians
and patients are denied the resources for anything more than at best
a pro forma consideration of diagnostic and treatment alternatives
and outcome probabilities. By the same token, the prevalence of such
methods of monitoring as bureaucratic and categorical reporting forms
which are used by managed care companies to build individual physician
practice profiles for the purpose of profiling and deselection, is
a further intrusion into the privacy patient-physician encounter
which threatens patient autonomy in conjunction with the consequences
of unanalyzed and therefore untreated or undertreated risk factors
for illness.
The managed care promoted fiction that patients consent to such intrusions
when they sign a pro forma informed consent form which is a condition
for their obtaining insurance coverage and reimbursement, is a band
aid for the hemorrhage of patient autonomy which itself unduly reduces
diagnostic analysis and clinical dialog. Rather than patients and
physicians settling for such pro forma band aids, what is needed
with today's advances in medicine and genetics is a system of health
care delivery which values the work involved for physicians to engage
in a meaningful diagnostic and informed consent process and protects
the privacy of the patient physician encounter.
Harold J. Bursztajn, M.D.
The writer is the author of Medical Choices, Medical
Chances: How Patients, Families and Physicians can Cope with Uncertainty.
New York: Routledge, Chapman & Hall, 1990.
