Charting Changes in the Doctor-Patient Relationship

Hippocrates wrote: “It is more important to know what sort of person has a disease than to know what sort of disease a person has.”

Part science and part art, the practice of medicine has changed drastically in the 6,000 years since Hippocrates first uttered his famous oath. This evolution in recent decades, as seen both in its practice by physicians and the expectations thrust upon it by patients, has influenced a shift away from the hands-on study of the body as a primary means of diagnosis to a more clinical approach, due to both the advances of modern medical technology and the wealth of health care related data accessible to all via the Internet.

A Little History

Thousands of years ago, medicine offered little more than diagnosis and prognosis. The doctor’s role was not to heal, but to predict. Over time, advances in both the understanding of human anatomy and the power of medical technology combined to revolutionize the medical expert’s ability to identify and treat a variety of illnesses. As physicians learned more about the interplay between each of the body’s organs, scientific discoveries began to shed new light on the mysteries hidden beneath the skin. The physician’s exam, once lauded as the cornerstone of diagnostic science, gave rise to the X-Ray, which led to the CT scan, to be followed by magnetic resonance imaging (MRI). In truth, such technological breakthroughs are the reason so many diseases once considered death sentences are now routine and treatable.

There is no question that these modern scientific marvels have greatly increased the twenty-first century physician’s ability to diagnose and treat his or her patients. But there is a cost. Initially intended as practical tools to gather additional data upon which to base a diagnosis, these new tests and procedures have become the central focus for many medical practitioners. The art of the physical examination, once so essential to both the diagnostic process and the emotional well-being of the patient, is becoming obsolete.

What Television and the Movies Can Teach Us About Attitudes Toward Medicine

These improvements in modern technology are in large part responsible for the transition that has taken place in the modern doctor’s bedside manner and overall attitude toward the patient. Nowhere is this trend more apparent than in the changing role of television doctors throughout recent decades. In the seventies, for example, Robert Young portrayed the kindly and world-wise general practitioner Marcus Welby, M.D., a man who struggled to treat his patients with compassion in a profession trending steadily toward specialized, impersonal care.

Such struggles were in vain, it seems, as Welby’s contemporary counterpart, Gregory House, M.D., uses his diagnostic brilliance as a means to keep himself always at arm’s length from his patients. No longer is a doctor thought of as a kindly old man who makes house calls and listens to his patients’ troubles and aches, he is now instead a young physician who hardly handles his patients while computing a checklist of ailments from which to order the proper panel of tests.

While the discussion of Drs. Welby and House above may portray two extremes in the doctor-patient relationship, the range of combinations in between has also appeared in television and film alike. In The Exorcist, Chris McNeil is a very concerned mother who desperately wants to identify the medical condition responsible for altering the behavior of her daughter Regan. The treating physician, relying upon early 1970s medical technology, offers his explanation:

“It’s a symptom of a type of disturbance in the chemical-electrical activity of the brain. In the case of your daughter in the temporal lobe, up here in the lateral part of the brain. It’s rare, but it does cause bizarre hallucinations.”

Late in the film, Regan’s physician returns to the McNeil Household during one of Regan’s more memorable performances. Though scientifically baffled, the physician is determined to hold firm to his instincts:

“Pathological states can induce abnormal strength, accelerated motor performance. For example, a 90-pound woman sees her child pinned under the wheel of a truck, runs out and lifts the wheels half a foot up off the ground. You know the story, same thing here.”

With no knowledge of the reasons for her daughter’s illness, Regan’s mother, like most people, was unable to engage in any meaningful debate about the accuracy of her daughter’s diagnosis. Armed with years of medical education and training, the ordinary doctor circa 1973 could strong arm just about anyone with his opinion. All this has changed, however, with the advent of websites such as WebMD, MedicineNet and

The rise of the Internet has made advances in medical science more accessible to patients, granting them new depth and scope, medically speaking. With such a wealth of knowledge literally at their fingertips, patients now want information immediately when it relates to the science of medicine, often researching both disease and cure on their own. For better or worse, doctors have to some degree lost the unquestioned sanctity that has historically accompanied their “mysterious” profession.

Rebuilding the Doctor-Patient Relationship

Though the benefits of modern technology are not to be overlooked, the changes they have instilled make it increasingly important for both medical practitioners and their patients to maintain an objective approach to one another. A well-rounded doctor would do well to incorporate newfound scientific resources with renewed emphasis on the physical exam and patient history, in an effort to once again personalize the medical experience. A wise patient must keep in mind that the Internet, while a practical educational tool, is no substitute for a medical degree and in-field experience.

Perhaps most important to improving the doctor-patient relationship is the need for communication. To get the most out of your doctor’s visit, it is essential that you express yourself while at the same time understanding the often complex issues and instructions your physician presents to you. Following is a set of guidelines to assist patients in their effort to communicate quickly and effectively, so that doctors have the information necessary to do their job and patients feel their needs have been addressed:

  • Be thorough. Your role is to provide the details on how you are feeling. The doctor will decide what is relevant.
  • Be honest. Your doctor has seen it all, and he or she is not there to judge you, but to heal you. Telling the truth about lifestyle choices, symptoms and concerns marks the fastest route on the road to recovery.
  • Ask questions. If something your doctor says about your condition or treatment is unclear, ask him or her to repeat it or put it in simpler terms.
  • Bring lists. The better prepared you are for your visit, the more relaxed you will be when questioned, and the more you will benefit from your doctor’s instruction.

With all the benefits provided by modern medical technology, it is clear that the clinical emphasis on diagnostic medicine is here to stay. As the relationship between physicians and their patients continues to shift, it is important for both sides to remember that the practice of health care is a partnership as well as a profession. By effectively opening up a dialogue in which information and concerns can be shared, the doctor is better able to assess the situation, while the patient is made to take a more active role in the course of treatment, leading to a more relaxed, balanced and satisfying experience for all involved.

The Visitor / Reducing Stress in a Hospital Stay

Aeschylus wrote: “What is there more kindly than the feeling between host and guest?”

The hospital stay is often a time of great stress for patients and their families alike. Recently, President Obama issued a directive for the creation of rules ensuring that hospitals protect the rights of patients to designate visitors, stating in part: “There are few moments in our lives that call for greater compassion and companionship than when a loved one is admitted to the hospital.” While the President’s comments have been widely debated, his underlying sentiment emphasizes the importance of reducing stress in a hospital setting for all those involved.

Let’s face it, no one wants to be in a hospital. Whether visiting a loved one or being visited yourself, the hospital stay poses a unique set of problems in that the presence of illness tends to tilt the scales of any relationship. Lying in a hospital bed surrounded by tubes and monitors, the patient is in a vulnerable state both mentally and physically. Separated from his or her natural environment, the patient is not only in unfamiliar territory but in the process of coming to grips with the fact that he or she is ill. Such a one-two punch often forces patients into crisis mode, leaving them feeling frightened and confused. In such a situation, the mere sight of a loved one is often enough to greatly reduce stress levels by assuring them that they are not alone in the situation.

But this burden must go somewhere, and it usually makes its way to the shoulders of the loved ones who come to visit. Family members, too, must navigate the shifting roles brought on by illness, as the physical and emotional toll of caring for a sick loved one can have a dramatic effect on everyday life. Such seemingly simple tasks as eating healthy, getting enough sleep, and addressing work responsibilities and personal commitments often fall by the wayside as time is sacrificed for the good of the patient. To make matters worse, stress is often increased by having to wrestle with concerns about the patient’s care, complex medical information, financial anxiety, questions of insurance and the possibility of long term issues after the patient’s discharge.

As difficult as it may be for people to watch a family member battle illness, for some groups the emotional distress brought about by grief or concern is further compounded by the struggle they must undertake to simply gain admittance to see their loved one. Though the President’s recent directive is a step in the right direction, the rights of gays, lesbians and unmarried partners both to visit and make decisions with respect to their loved ones’ care have historically fallen short, forcing them to watch from the sidelines as the patient battles his or her disease without the support of the partner. In addition, the elderly, who are often balancing the aforementioned stressors with additional feelings of grief and impending loss, must allow for issues deriving from potentially weakened immune systems, limited mobility and lapses in cognition, factors which can impede their ability to offer support. Children, too, can have trouble when trying to see those closest to them, as many hospitals have strict regulations prohibiting visitation by those under seventeen.

In the event that you are allowed to visit your loved one, good communication skills and a positive outlook are essential when providing comfort. The stress level of a patient can be either reduced or increased by the visitor, so it is important to remember that ultimately the needs of the patient come first. Following are guidelines to assist the family member so that his or her visit serves to calm the patient, rather than add to an already stressful situation.

● Ask permission to visit. While many patients enjoy company, some do not like for others to see them infirm or tired, or simply do not feel up to having guests. If you suspect you are intruding, politely ask if another day would suit them better. The key is to let the patient know that you are thinking about them.

● Gauge the effect of your visit. A family illness can sometimes force interaction between estranged members. However, this is no time to address old wounds. What matters now is to offer support in a time of need.

● Stay positive. Though your loved one’s hospital stay may be taking its toll on you, it is important to keep the patient’s thoughts on the task of getting better. Complaining about the situation or introducing feelings of guilt or resentment will only increase the overall stress level.

● Keep your visit short. No matter how much your loved one may enjoy your company, he or she needs plenty of rest. The fact that you have taken the time to see them is what matters, not the length of your visit. The simple act of seeing a friendly face can work wonders.

● Don’t visit when you are ill. Though you’d like to show your support, visiting a loved one while sick is never a good idea. Patients in hospitals often have compromised immune systems which can cause additional complications during treatment. Instead, feel free to call or write until you are feeling better and are no longer contagious.

● Participate in the treatment. Should your loved one approve, it may be a good idea to get involved in the process by familiarizing yourself with the patient’s condition, symptoms, and outlook. You may also want to introduce yourself to all related medical staff. This is a great way to remind your loved one that he or she is not alone, and that someone who cares is looking out for their best interest.

● Take care of yourself. While your primary focus may be on your loved one, it is important to note that you cannot be of help to him or her if you get sick yourself. Spend a few minutes every day doing something you enjoy, and try to eat well and get as much sleep as possible. The stronger you remain during this experience, the more you will be able to provide your loved one with the support he or she needs during this trying time.

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340B and Hospital Systems0

The Department of Health and Human Services (“HHS”) responded to comments published in the Federal Register that a hospital  enrolled in the 340B program as a Covered Entity may treat its off-campus clinics and satellite hospitals as part of the Covered Entity, provided the off-campus clinic or satellite hospital is included on the Covered Entity’s Medicare Cost Report.[1]  HHS also declared that off-campus clinics and satellite hospitals may be properly included on the Covered Entity’s Cost Report where they meet Medicare’s tests for provider based status, as outlined at 42 C.F.R. § 413.65(d-e).[2]

(1)        Criteria For All Facilities

42 C.F.R. § 413.65(d) outlines the criteria for all facilities to receive provider-based status.  The requirements are divided into five main categories, with two categories in particular that typically affect hospital systems: (a) licensure and (b) clinical services.

(a)        Licensure

With respect to licensure, as stated above, “the satellite facility and the main provider are operated under the same license, except in area where the State requires a separate license for the . . . satellite facility.”[3]  One example of a state with this requirement is Nevada as Nevada law requires all hospitals and clinics, among other providers, to be licensed by the Nevada State Health Division[4].

(b)       Clinical Services

With respect to clinical services, the two entities need to be integrated such that (i) the professional staff of the off-campus clinic must have clinical privileges at the Covered Entity’s main campus; (ii) the Covered Entity provides the same monitoring and oversight as it does for any department; (iii) the medical director of the off-campus facility needs to maintain a reporting relationship with the CMO of the Covered Entity and be supervised and accountable to the CMO; (iv) the Covered Entity’s staff committees are responsible for the off-campus clinic’s medical activities, including, quality assurance, utilization review, and coordination and integration of services; (v) the entities have integrated medical records; and (vi) the off-campus clinic and the Covered Entity are integrated such that patients treated off-campus have full access to facilities and services of the covered entity.[6]

(2)       Criteria For Off-Campus Facilities

42 C.F.R. § 413.65(e) outlines the criteria for off-campus facilities to receive provider-based status.  The requirements are divided into three categories: (a) ownership and control, (b) administration and supervision, and (c) location.

(a)        Ownership and Control

With respect to ownership and control, the Covered Entity’s control of the off-campus clinic must be evidenced by: (i) 100% ownership; (ii) accountability to the same governing body; (iii) organization under the same governing documents and bylaws; (iv) and final administrative responsibility laying with the Covered Entity.[7]

(b)       Administration and Supervision

With respect to ownership and control, the Covered Entity must hold the off-campus clinic accountable as evidenced by: (i) direct supervision of the off-campus clinic; (ii) accountability to the Covered Entity’s governing body, and (iii) integrated billing, records, human resources, payroll, employee benefits, salary structure, and purchasing services.[8]

(c)        Location

With respect to location, the Covered Entity and the off-campus clinic must meet one of the following: (i) located within a 35 mile radius of each other; (ii) the Covered Entity is disproportionate share adjustment of greater than 11.75% and is owned either by the state or local government, is a nonprofit corporation granted governmental powers by the state, or is a private hospital with a State contract to provide clinic services to low-income individuals; (iii) the off-campus clinic has at least 75% of its patients from the same zip code as the Covered Entity or 75% of the off-campus clinic’s patients were treated at the Covered Entity; (iv) 75% of patients in the off-campus facility’s zip code receive treatment at Covered Entity; or (v) the off-campus facility is a children’s hospital and meets 6 other criteria.

[1] 59 Fed. Reg. 47884, 47885 (Sep. 19, 1994).

[2] Id.  The response in the Federal Register directs the reader to “Provider Certification, State Operation Manual, section 2024.”  Section 2024 in turn directs that, “all non-hospital providers of service under Medicare that state they are part of a single hospital must meet the criteria for provider-based designation in §2004 in order to be treated as a single hospital for payment purposes.”  Next, Section 2004 directs the reader to 42 C.F.R. § 413.65 for the criteria used to determine provider-based status.  Finally, the Federal Register cited above enumerated several criteria as examples, all of which are found in C.F.R. § 413.65.  Thus, while the Federal government (surprisingly) was less than clear on the test for determining whether an off-campus clinic or satellite hospital may be treated as part of a Covered Entity, I am confident that the provider-based status test is the applicable test to make such a determination.

[3] 42 C.F.R. § 413.65(d)(1) (2012).

[4] See Nevada Revised Statues § 449.030 (2012).

[5] 42 C.F.R. § 413.65(d)(1) (2012).

[6] 42 C.F.R. § 413.65(d)(2) (2012).

[7] 42 C.F.R. § 413.65(e)(1) (2012).

[8] 42 C.F.R. § 413.65(e)(2) (2012).