Last June, a study done by the Commonwealth Fund in Boston, Los Angeles and Miami showed that 41 percent of managed care patients surveyed had changed doctors at least once in the last three years. Mark Siegler determined that more than 70 physicians, nurses, managers, trainees, students and managers had access to a hospitalized patient's chart. Today, that number can be multiplied by three orders of magnitude. As information systems record and beam bits of data we thought we'd told no one else to a cyberspace too big to think about, confidentiality of medical records seems like food for earthworms. There's a flip side to truthtelling here.
Advocacy is the first rule of traditional medical ethics.
Happily for physicians, the scientific philosophy implied by these goals has also been financially rewarding. Yet in managed care, the financial incentives are reversed, and physicians face disincentives to refer or to prescribe an off-formulary medication. To minimize the distortion of physician judgment, proposed rules from the Health Care Financing Administration limit the amount of compensation physicians can risk to a maximum of 30 percent. Medical practice is nothing if not personal. Patients in the waiting room do not think of unidentifiable others when they are in the office, cold and naked, still waiting to be seen.