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OB/GYN Editorial MAY 2004
The Physician as a Risk Manager
Terence W. Starz, MD
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There has been a subtle yet profound change in the physician's
role and responsibility in caring for patients. Traditionally,
physicians have served as their patients' health care advisor to
prevent, diagnose, and treat diseases with the goal of achieving
the most favorable quality of life. Inherent within this process
has been the understanding that the most effective, up-to-date
resources available would be used.
Over the past two decades, there have been enormous advances in the understanding
of normal body functioning, disease mechanisms, and diagnostic and therapeutic
tools. As a result, the complexity of providing appropriate care has dramatically
increased. Sir William Osler's adage at the turn of the century that, "The
art of medicine is keeping the patient entertained while nature takes its course," is
now an anachronism. The effective utilization of our modern health care advances
can have a dramatic impact on the course of many diseases.
A new facet of the physician's activities has become the direct responsibility
and accountability
to manage risk. Physicians have always understood that the practice of medicine
was a "risky business," and the results of our efforts may not be
able to return the patient completely back to normal. Because of the complexity
of the human body and the limitations of our available technology, there is
no absolute guarantee of outcomes; there is only the likelihood that a particular
outcome will occur.
Multiple risks are involved in patient care: the predictability of evaluation
tools, the correctness of the diagnosis, the timeliness in making the diagnosis,
the choice of therapy, and the compliance of the patient with the physician's
directives. Physicians must weigh the potential good effects of our activities
versus the adverse effects versus what will happen if nothing is done at all.
Our knowledge and skills are important elements in the equation; however, they
must be balanced with other complex factors and the practice of evidence-based
medicine. Patients' expectations of our performance are very high, yet often
unrealistic and unforgiving. In today's cost-conscious and litigious environment,
the physician is placed in a conundrum in which there is an overpowering tension
between what constitutes appropriate care and the ability of our society to
pay for it.
An inherent component of human nature is to minimize risk, especially regarding
our body. Where does the ultimate responsibility for managing health risk lie?
With every new patient that I see, I ask the question, "Who is responsible
for your health?" I am surprised that more than one half of the patients
reply, "Doctor, you are." This answer underlies the new complexity
of the physician's role. We must understand and accept the great responsibilities
of being risk managers in situations in which there are tremendous challenges
and uncertainties that are measured by outcome data, odds ratios, and cost
benefits. Yet, at the same time, we must fulfill our time-honored responsibility
of providing compassionate care for our patients.
Terence W. Starz, MD
Associate Advisory Board Member
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