1. Medical Organization Professional dominance McDonaldization Newfound power of the patient Light– “Patients, governments, and corporate purchasers are taking back the cultural, economic, and even the technical authority long granted to the medical profession”

2. Countervailing powers Interaction of powerful actors in a milieu of interdependence Dominance is contextual The context has changed Unbalanced power creates the need in a system to create and reward polar opposite power

3. Countervailing Power Opens the door to new relationships and alliances in medicine Example—emergency medicine Economic structure wanted more control Prior authorization EMTALA Melding of patient and medical interests—reasonable patient standard

4. Nursing Helper Now separate profession with theory and practice parameters Co-professionals Gender considerations

5. Allied Professionals Also have separate nature and rules/power Team conceptualization now

6. Emergency Medicine Alliance between patients and doctors made visit to ER guaranteed by law and not subject to prior restraint Consequences to hospitals, specialists, patients, payers and ED physicians

7. American Medicine Overspecialized—why? Costly Unnecessary treatment No controls on medicine and medical industries Payers complained and they gave money to legislators

8. What we expect from medicine Quality Safety Involvement Privacy Financial Rapid, always available, and on demand

9. American medicine Trust eroding Fixed payments and controlled costs Legal and administrative controls on medical practice Controls on research Corporate industry—profit matters

10. Consequences to present trends Stratification of who receives care and what care is received cuts in services cuts in professional staffs reduced quality paperwork, bureaucratization and regimentation

11. Practice patterns Paperwork—up to 60% of physician time Patient time—5-7 minutes per patient Incomplete diagnosis despite better technology Physician salaries drop by 30-60% Changes in practice patterns—less work, less obligation, defensive practice

12. Economic Concerns Capitalist doctors Managed care and the failure of the management model Decline in reimbursement

13. Trust Behavior that is consistent and beneficial to self, others engenders trust Credibility Compassion Interpersonal and social Emotional bonds

14. Trust Bonds—transference, social contract Interpersonal trust because of personal integrity and altruistic behavior Social trust because of Obligations we have taken willing to protect and serve Institutional and professional trust distinguished

15. Factors in trust responsive, compassion Feedback, information optimism Affiliations with credible institutions

16. Erosion of trust Doctors are answering to others Compassion to standard practice Credibility questioned Who is the master of the doctor The relationship of managed care to trust in the doctor-patient relationship

17. Example Medicaid pays 4% of each total bill Physicians can opt out of the program New Medicaid patients cannot find doctors Solutions?