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Monday, November 07, 2005

JAMA commentary: Doctors and Lawyers-can't we just get along?

The October 26,2005 issue of JAMA published a commentary by a physician and an attorney who give their opinions on improving relations between physicians and attorneys. While admitting that malpractice concerns is a major driver in the antipathy between the two professions, they also argue that core values are actually similar but that we differ in approaches to conflict resolutions. They quote a 1987 publication by D.M.Fox ("Physicians versus lawyers:a conflict of cultures, in Dalton H. Burris,S. Ed. AIDS and the Law. New Haven,Conn.Yale University Press: 1987:367-376) in which the author says that are disagreements about five issues:the nature of authority,how to resolve conflicts,the relative importance of substance and procedure, the nature of risk and the legitimacy of politics as a method of solving problems. Fox may have adduced convincing evidence that these factors underlie differences between the two professions, but when is the last time you argued with a lawyer at a cocktail party about the fine points of the relative importance of substance and procedure? They suggest to avoid further "ruptures" in doc-lawyer relations,we should "dialogue" and emphasize shared values and "concerns for patient safety" Now, who could be against patient safety (or quality, or Mom or apple pie) ?
However, I doubt if patient safety is the driver for this article. I believe we find what this article is all about in the final section entitled "next steps". Here we learn that we should dialogue with lawyers in part to learn how to "set limits on resource use".
This limit setting , of course, will be done " in a manner that accommodates both individual autonomy and society wide conceptions of fairness ". Both of the JAMA article's authors are affiliated with Public Health and/or health policy departments, which are typically the sources of discussions regarding limits on resource utilization,which translates into limits of services patients receive. Why is it that clinicians seems to be concerned with what they can do for patients and so often health policy wonks initiate discussions about how we can limit what patient receive? To talk of the need for resource use limits is to assume too much is being used which translates to too much being done for patients which translates further to a third party deciding that the individual decisions of doctors and patients about clinical managment issues have lead to a undefineable "overuse" of resources.Obviously,many in the health policy business believe that patient treatment is too important to leave to the myopic lens of doctor and patient.
The major reason for antagonism to attorneys by physicians is the malpractice issue. Talking about abstract core values the two professions allegedly share and initiating dialogues about how "we" can limit resource use will not change this.My jaded view is this a bait and switch article, the discussion begins with how to improve doctor lawyer relations and ends with a call to to work out way to limit resource use.

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