Pearson S D
Harvard Medical School and Harvard Pilgrim Health Care, Boston, Massachusetts, USA.
Ann Intern Med. 2000 Jul 18;133(2):148-53. doi: 10.7326/0003-4819-133-2-200007180-00014.
How should physicians respond to the growing tension between care and cost? One option is to reinforce the ideal of doing everything to further the best interests of the individual patient. Others, however, have argued that because health care resources are shared and limited, physicians should consciously participate in rationing by saying "no" to patients' requests for some marginally beneficial services. But even physicians who endorse the idea of rationing wonder whether patient-physician relationships could ever survive a frank admission of rationing at the bedside. This article explores the idea that caring about costs can be brought to the bedside in a way that will sustain trust among patients and the public. By illustrating a hypothetical case and the ensuing conversation between a physician and her patient, a mode of "proportional" patient advocacy is presented in which physicians can remain forceful agents for patient good while acting within a framework that admits to the boundaries of responsible budgets for health care needs.
医生应如何应对医疗护理与成本之间日益加剧的紧张关系？一种选择是强化为促进个体患者的最大利益而竭尽全力的理念。然而，其他人则认为，由于医疗资源是共享且有限的，医生应通过对患者要求提供一些边际效益不大的服务说“不”，自觉参与医疗资源的分配。但即使是赞同资源分配理念的医生也在思考，在床边坦率承认资源分配的情况下，医患关系是否还能存续。本文探讨了这样一种理念，即关注成本可以以一种能维持患者与公众之间信任的方式带到床边。通过阐述一个假设案例以及随后医生与患者之间的对话，呈现了一种“相称性”患者权益维护模式，在这种模式中，医生在承认医疗保健需求责任预算边界的框架内行事时，仍可有力地为患者谋福祉。
