Patient advocate: To be or not to be?

Fifty years ago, just as the gas-lit cobbled, streets and brewers’ drays of old London were disappearing, I first entered the wards of a London teaching hospital. There I began listening and talking to patients, and I have been doing so ever since. I do not remember Hippocrates being mentioned but we didn’t have to be told that the patients interests were paramount; it was implicit in the demeanor and behavior of everyone around. We were the patients’ advocates. My mentors were great clinicians, many attracting patients from all over Europe because of their reputations for excellent care. With men and women like these there was no question where our loyalties lay.

The next few years saw astonishing advances in the scientific basis of medical practice that increased our ability to be of service to our patients. Despite these momentous advances, the essence of medicine—our obligation to the patient—never changed, even though the weapons to discharge it did so beyond imagination. But over the years something else was taking place that had the potential to threaten the essential bond of trust between us and our patients and which in part derived from this success.

The National Health Service in the United Kingdom was just being ushered in as I entered my pre-clinical years. It is extraordinary now to remember that at that time it was believed that this civilized piece of social engineering would save money. Since absenteeism due to sickness would be a thing of the past, productivity would rise and with it national income. It was even suggested that the system could be exported and become an important source of national revenue. It was not long before this mirage faded into memory.

We now know that a society is far more likely to be impoverished than enriched by providing basic medical care, let alone the best available, for all its citizens; indeed there is a real possibility that no state will ever be able, let alone willing, to provide the funds for all that medicine has to offer. This is because, in a sense, every triumph stores up trouble for tomorrow, as the increasing incidence of dependent infirmity with advancing years so aptly shows. That is not to say that progress is at fault, but to state the obvious, that the better we succeed now the more we must pay later. In this wilderness of underfunding, the need for doctors to be advocates for their patients is more important than ever and must not be abandoned, as some are beginning to suggest.

One of the greatest threats to our ability to act as advocates for our patients is the failure of our leaders to address in open and honest debate the inevitable shortfall in funds inherent in the practise of medicine. With input from all players, good ideas and possible solutions are bound to come forth. But the demeaning of doctors and the failure to consult them or include them in discussions leads to speculation that the aim is to curb costs by choking doctors in ways that could blunt their ability to meet their patients’ needs.

Whatever the authorities attempt we must ensure the basic ethic of our profession is not destroyed. Central to this is the sanctity of patient advocacy and the inviolability of the patient-doctor relationship. These principles are so essential to our continuing civilization that alarm bells should ring whenever they are threatened. Is this what Barer and Stoddart are saying in their report of 1991 which was widely endorsed by health care planners at the time?

“There is a continuing evolution from the view of physicians as private agents for their patients’… interests, to the view of physicians as clinically skilled agents serving the collective goals of a publicly funded health care system….”[1] That is to say, agents of the state.

Is it possible that employed in this capacity by the state, physicians could fail to advocate for their patients? Consider this: “Decisions not to treat kidney patients are being taken by doctors all the time. Usually the patient does not understand that he could have been treated and goes away to die quietly….” These patients believed they were consulting their advocates but they were wrong; they were facing the agents of the state and so, if only by default, their executioners, doctors on the government payroll. Soviet Russia? No. Britain.[2]

The main purpose of doctors is caring for patients, but when they depend for their livelihood on an organization whose agenda, however otherwise legitimate, is not primarily the welfare of the sick, their ability to act as patient advocate is potentially impaired. There are hundreds of examples of doctors on the payroll of prisons, armies, drug companies, and universities who have betrayed their patients because of their divided loyalties.

Now that the Faculty of Medicine at UBC is known to be dangerously underfunded,[3] there is a concern that they will see an advantage in pooling, with other income, funds designed to pay clinical faculty for patient services. Clinicians paid from this pool would then be on their payroll.[4]

 To avoid this danger and to uphold the principle of patient advocacy and physician autonomy, the University Clinical Faculty Association was formed in March 1998.[5] Clinical faculty have a plethora of role models with years of experience in handling patients in the clinic and at the bedside. They are naturally the ones to teach the art of delivering care to the doctors of tomorrow and so ensuring that the basic ethic of our profession is not only understood, but endures. Teaching the science that importantly underpins this art is the responsibility of our partners in the Faculty of Medicine.

 The future of medicine may be considered in many ways, but one thing is clear. Medicine has no future if doctors become hired hands and abandon these basic principles. The University Clinical Faculty Association is acutely aware of this danger and will play an important part in passing to the next generation of doctors not only the need for, but also the determination to defend these principles, on behalf of all society.

Dr Rae is the president of the University Clinical Faculty Association and clinical professor emeritus of medicine, University of British Columbia.