Does Oversight Threaten the Doctor-Patient Bond?

February 27, 2009
Doctor and Patient
Does Oversight Threaten the Doctor-Patient Bond?
By PAULINE W. CHEN, M.D.

The most recent debate in health care reform has centered on the $1.1 billion set aside in the economic stimulus bill to compare the effectiveness of different treatments for the same illness.

Supporters of the provision believe that such “comparative effectiveness” research will help to identify ineffective therapy, improve quality of care and ultimately decrease the time and effort, not to mention the dollars, spent on treatments that don’t work well.

But critics warn that such research could ultimately lead to a one-treatment-fits-all approach and that the government could become an unwelcome third party, dictating “appropriate” decisions in the doctor-patient relationship.

I’m not so sure, though, that doctor-patient relationships are currently free of third-party oversight to begin with. Moreover, I am not convinced that oversight necessarily weakens a doctor’s connection with his or her patients. In fact, when done well, oversight can actually strengthen that relationship.

It was shortly after residency when I first learned I would not have the kind of direct doctor-patient relationships I had imagined going into medicine. As a newly trained surgeon, I took care of a tall and soft-spoken woman I’ll call Alice. She was 67 when I first met her, with thick grey curls that fell around her heart-shaped face, and she prided herself on being a housewife, grandmother and, with her husband, a lifelong volunteer for the Pasadena Tournament of Roses. Her primary care doctor had diagnosed her with a cholangiocarcinoma, a tumor of the bile ducts, and she came to the clinic where I worked for a surgical consultation.

Alice’s tumor, it turned out, was small on CAT scan, barely a smudge on the large expanse of her liver. I told her we could likely remove the tumor with an operation, and her blue eyes sparkled in response.

Her husband, who was sitting so close to Alice that I could see their knees touching, grinned and said to me, “We’ll send you to the Rose Parade next year.”

But the following morning, the clinic’s nurse coordinator stormed into my office. “The insurance company is refusing to authorize the operation,” she fumed. “Alice is devastated. Her husband had to get on the phone to finish our conversation.”

“You have to convince the insurance company to change its decision,” she continued, handing me a slip of paper with their phone number. “And let’s just hope you don’t get that woman who denies everything.”

I called the insurance company and spoke for 10 minutes with a male voice, summoning what treatment statistics I could. But when his response was simply “Uh-huh,” I found myself describing Alice and her family. “She’s a dedicated volunteer for the Tournament of Roses,” I heard myself say.

I eventually did get the authorization; Alice got her operation. And one New Year’s Day, after politely declining two years’ worth of offers, I sat on the bleachers in the V.I.P. section, holding the ticket Alice and her husband had sent me and watching floats bedecked with roses pass by and brilliant brass instruments reflecting the southern California sun.

It’s been several years since I took care of Alice, but I still get upset when I think about how I needed to plead with an anonymous voice for what was right for her. While I now accept the constant presence of an invisible and powerful third party in my interactions with patients, I can still feel my shoulders tighten whenever I hear the word “authorization.”

But it is not the third party per se that causes the hairs on the back of my neck to rise. It is the sense that some of their decisions are based not on well-researched recommendations but on interests, agreements and circumstances that have little or nothing to do with good care. And because I know it is possible to have oversight that strengthens the doctor-patient relationship while relying on evidence-based treatment recommendations.

I know because I have been part of one of the most successfully regulated medical fields in this country: transplantation.

Few doctor-patient relationships are as intensely monitored as the one between a transplant patient and his or her transplant doctor. Since the 1984 passage of the National Organ and Transplant act, a third party has reviewed every donor case and every transplant case in the United States. For the last 23 years, that third party has been the United Network of Organ Sharing, or UNOS, a nonprofit organization under contract to the Department of Health and Human Services.

While the Secretary of Health and Human Services is responsible for regulatory enforcement, UNOS is in charge of clinical oversight. UNOS develops policies that promote the equitable and ethical use of organs using evidence-based studies and consensus among representatives of its many constituent groups — health care professionals, transplant candidates and recipients, organ donors and their families, ethicists and volunteers.

One example of such a policy is the strict separation of responsibilities. Transplant doctors are not allowed to participate in donor patient care or enter the operating room until after a donor patient’s death. The doctors who care for the living patient ultimately determine when a potential donor is brain dead, not the transplant team.

I called Dr. Robert S. D. Higgins, current president of UNOS and chairman of cardiovascular and thoracic surgery at Rush University Medical Center in Chicago. “By mandate,” he said, “all that UNOS is required to do is ensure the best use of precious organs and manage the system with sound medical judgment and some kind of objective criteria.”

“That being said,” Dr. Higgins added, “I do think UNOS has provided a framework for the success of transplantation. For instance, the comparative benefit of transplantation has been proven time and time again in kidney failure patients. If the transplant field was a random unregulated process, it might not have advanced to this stage.”

UNOS and its policies provide a collective framework — a common language, a shared understanding — within which every transplant doctor and patient in the country makes individual decisions. And because of the transparency, consistency and evidence-based research supporting this framework, all transplant doctors and patients know where their third party stands. There is a no abrupt reversal of patient expectations because authorization is suddenly denied, and there is no pleading for authorization on the phone with a disembodied voice.

As Dr. Higgins observed, “UNOS is a shining example of how the system can work.”

I would have to agree.

Join the discussion on the Well blog, "Comparing the Costs of Medical Treatments"

http://www.nytimes.com/2009/02/27/health/26chen.html?_r=1&ref=health