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Ideas and Opinions |

Caring and Cost: The Challenge for Physician Advocacy

Steven D. Pearson, MD, MSc
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Copyright ©2004 by the American College of Physicians


Ann Intern Med. 2000;133(2):148-153. doi:10.7326/0003-4819-133-2-200007180-00014
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How should physicians respond to the growing tension between care and cost? One option is to reinforce the ideal of doing everything to further the best interests of the individual patient. Others, however, have argued that because health care resources are shared and limited, physicians should consciously participate in rationing by saying “no” to patients' requests for some marginally beneficial services.

But even physicians who endorse the idea of rationing wonder whether patient–physician relationships could ever survive a frank admission of rationing at the bedside. This article explores the idea that caring about costs can be brought to the bedside in a way that will sustain trust among patients and the public. By illustrating a hypothetical case and the ensuing conversation between a physician and her patient, a mode of “proportional” patient advocacy is presented in which physicians can remain forceful agents for patient good while acting within a framework that admits to the boundaries of responsible budgets for health care needs.

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Figure.
Two models of physician advocacy.Top. Darwinian advocacy.Bottom. Proportional advocacy.

In this model, societal pressures to control costs are applied unevenly, and even capriciously, resulting in a competitive relationship among patient–physician dyads for available resources. Some patient–physician dyads gain preferential access to services, whereas others are forced to accept less. In this model, patients and physicians are viewed as part of a moral community in which costs are controlled through group deliberation and decision making. Physicians are called upon to ration at the bedside with the open knowledge and collaboration of their patients and the broader community.

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