Creating a new patient-provider relationship: a personal challenge.

The Challenge of a New Ethos In his article, "Promisekeeping: An Institutional Ethos for Healthcare Today," David Thomasma has laid down what may be the most important challenge facing the leaders of healthcare institutions today. Put as simply as possible, it is to create a new patient-provider relationship that works in the best interests of the patient at a time when a torrent of trends and incentives threaten to sweep those interests aside. This challenge is not directed at the healthcare system as a collective, and it does not have an academic, global, or visionary ring to it. Rather, it is rooted in the sometimes harsh reality that there is no systematic way to resolve the conflict between the apparent lack of resources to care for people and the human hope, instinct, and expectation of healthcare. In fact, for all the discussion of "managed care," the delivery of medical services remains largely an episode-illness and injury-encounter mechanism. Although some of the building blocks of this new patient-provider ethos can be expressed in institutional policies and protocols, giving the idea a presence in today's chaotic healthcare environment is a deeply personal challenge, touching on the most basic individual values. It is far easier to create rules for disclosure, processes for appeals, and methods for electing ethics committees within health plans than it is to instill a "culture of promisekeeping" that will work across healthcare settings and over time. Thomasma has clearly identified the choices that will confront everyone from caregivers at the bedside to executive, physician, and governance leaders every time they look a patient or a community in the eye. As we pay "closer attention to the relation of clinical interventions and economics," we must design effective ways to give a voice to those who actually provide the care and those who receive it. The Voice of the Patient The last four words deserve particular emphasis because Thomasma has put his finger squarely on the element of this new ethos that we are doing the least about: talking with our patients in particular and the public in general about how the changes in the delivery of and payment for healthcare services will affect them. Some of this is intentional, but much of it, I think, stems from a tradition of mystery and unspoken promises that has surrounded healing institutions and professions. From the point of view of the provider, the tradition's unspoken promises were that patients were always receiving the highest quality of care and the best efforts of the caregivers; of course we were doing the right things and doing them well. From the patient's perspective, the trust in physicians and institutions was traditionally strong. Hospitals were mysterious places-the public seldom saw what went on behind the scenes and had little or no understanding of the complex systems and relationships on which the patient care process was built. But all that has changed. Beginning in the 1980s, the federal government released Medicare mortality data and the public got its first real glimpse behind the mystery. That data raised legitimate questions about the comparative quality of care being delivered to elderly Americans, and, although it sent shock waves through the field, it broke an ancient barrier. Many sectors of the public-patients, government, business, insurers, and the media, to name a few-wanted to know more about what we do and how we do it. They began, in fact, to ask the question Thomasma poses as one of his central points: Are we doing the right things and doing them well? Regrettably, our track record at initiating a dialogue with the public has been weak. We relied on the traditional trust I mentioned earlier, even though it was eroding beneath our feet. No matter what cost constraints government or insurers levied, we assured the public that we always kept the quality of care high. When a severe nurse shortage occurred a decade ago, we again assured everyone that the quality of care never was affected. …