Social Factors

Macro Determinants of Clinical Decision Making

Sociologist Talcott Parsons provided a theoretical perspective on the doctor-patient relationship (D-P relationship), reflecting the situation in the United States around the middle of the 20th century; his view dominated thinking in health services research for the remainder of the century. The Parsonian view of the D-P relationship is depicted in Figure 1, and several features should be highlighted:

• The spotlight of analysis was generally on the doctor, who enjoyed high social status and had a [Page 1047]dominant role as the repository of valuable medical knowledge and expertise.
• Only two actors were involved in the interaction, with the doctor acting professionally and being altruistically motivated to serve only the patient's interests.
• The patient occupied a subordinate and reciprocal role and was expected to trust the doctor's judgment and follow (his) clinical recommendations (credat emptor was the prevailing ethos).

Many health services researchers and decision theorists still employ this idealistic perspective, even though the D-P relationship today (within which clinical decisions occur) bears little resemblance to earlier formulations. The world of healthcare has shifted beneath decision theorists' feet, producing results of little policy relevance and suggesting educational efforts that are unlikely to produce desired changes in clinical practice. Some indication of the magnitude of the transformation of U.S. healthcare is evident in the words used to describe the once special D-P relationship—the doctor has become “a provider,” the patient is now a “client,” and the relationship is now considered “an encounter.”

Some of the major new influences affecting clinical decision making within the new client-provider encounter (C-P Encounter) are illustrated in Figure 2 and include the following:

• Physicians are increasingly forced into specialization (generalists are in short supply) and most are full-time salaried employees in large and increasingly concentrated organizations.
• Corporatized physician employees are required to go along (with clinical guidelines and pay-for-performance schemes) if they are to get along (receive promotions and salary improvements).
• The spotlight is now on a knowledge-empowered patient/client who occupies center stage and is the ultimate object of all revenue in a profit-driven healthcare system.
• Insurance companies dictate what exactly any clinician can actually decide for any given case (test ordering, referrals, prescriptions, and follow-up).
• Pharmaceutical companies advertise directly to consumers and suggest that they should ask their providers for specific medications. “Doctor knows best” is no longer the prevailing viewpoint.
• Widely publicized reports of financial kickbacks and clinical malpractice, as well as recognition that doctors may now serve several masters, appear to have eroded trust in the profession of medicine (as with car repairs, caveat emptor is the emerging ethos). The popular media no longer portray doctors as cultural heroes— compare Marcus Welby, MD with today's House or Green Wing.

Unlike the one-on-one, closed-system relationship of the past, clinical decision making is now required to occur on an ever more crowded stage (Figure 2). The spotlight is now on the patient as an object of revenue (client-centered care for an objectified condition); the patient is digitally empowered and activated by private (mainly pharmaceutical) interests; while supposedly making decisions solely in the interest of the patient, doctors are now required to also serve their corporate employers (there is no guaranteed coincidence of interest); the possible range of clinical actions and costs is dictated by a patient's health insurance (assuming that they have such); the state (government) is now essentially an onlooker, unwilling to protect the prerogatives of doctors and concerned to reduce the burden of ever-increasing healthcare costs. Surveys reveal high levels of physician dissatisfaction with their workplace and complaints about administrative encroachments on clinical autonomy.

...