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All fall down.

If we can trust recent public surveys, what we have in these United States are some serious failures to communicate - between doctors and their patients, and between health care experts and the general public.

For some time now patients have been complaining about their relationships with doctors. A poll conducted in 1990 by Miles Inc. revealed that dissatisfaction with a physician led one in four patients to switch doctors at least once. And more recently surveys by the American Medical Association and the Harris organization have shown that patients are losing their faith in physicians who, they feel, are greedy and arrogant, don't spend enough time with them, and are either unwilling or unable to offer clear explanations (Sonia L. Nazario, "Medical Science Seeks a Cure for Doctors, ..." Wall Street Journal, 17 March 1992).

The National Board of Medical Examiners is exploring ways to improve the situation. In a pilot program underway at the University of Southern California and the University of Illinois, medical students are being tested not only on their clinical competence, but on compassion and bedside manner as well. Graduating students examine sixteen mock patients with different "ailments." The "patients" in turn grade the would-be healers, using a checklist to score doctors' questions during the fifteen-minute exams, and a five-point scale to evaluate the "warm-and-fuzzy factor" of interpersonal skills. Just what - or how much - being able to pass the exam actually says about students' future performance with real patients in the less-than-ideal world of clinical practice is still an open question. The program at least takes patients' complaints seriously and lets students know they have to try.

Similar discontents seem to be at issue at the opposite end of the communication spectrum. The Public Agenda Foundation has just released a report (Faulty Diagnosis: Public Misconceptions about Health Care Reform) on how differently health care experts and the general public perceive our health care crisis. While experts define the "cost problem" as rapidly rising overall expenditures, the public sees it as a matter of how fast their own out-of-pocket expenses increase - some people surveyed were very surprised to learn that the U.S. now spends more on health care than on defense.

Where experts attribute rising costs to a complex etiology, the public finds a simpler explanation in greed (on the part of both providers and malpractice attorneys) and wasteful use of resources. Experts distinguish costly and inappropriate from costly but appropriate use of medical technology, for example, but John Q. and colleagues often see only abuse and wastefulness.

So too, there's considerable confusion on the question of national health insurance: despite broad professed support, it turns out that only about 31 percent of Americans define national health the way experts do. To quote one respondent, "I am for national health care, but I don't want the government involved."

Compounding the situation, physicians seem increasingly disillusioned with their chosen profession. A steady stream of newspaper articles, for example, reports their frustration with cost containment schemes that have them spending as much time pushing paper as seeing patients, all under the watchful eyes of utilization reviewers and risk managers.

Doctors ignore patients, bureaucrats ignore doctors, and nobody - experts, professionals, or public - can agree on just what's wrong with the health care system or how to fix it. What we have here.
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Author:Crigger, Bette-Jane
Publication:The Hastings Center Report
Date:Jul 1, 1992
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