[Fragmentation of the doctor-patient relationship as a result of standardisation and economisation].
Standards, guidelines and evidence-based medicine are suitable means to strengthen the doctor-patient relationship, but will have the opposite effect if they are unrelated to the subject and fail to address the patient's needs. This may be the case with collective agreements in terms of socialised medicine which serve to restrict the patient's individuality in favour of rigid austerity measures and rationing. For this reason, rationing can only be a political instrument; it should never be applied to the doctor-patient relationship. Evidence-based medicine is another important decision-making tool that is also applicable to individual cases. Follow-on consequences regarding the law, science, politics and industry are often disregarded. The claims formulated in evidence-based and thus legally enforceable guidelines are going to increase the demands made on every individual doctor. The movement of evidence-based medicine can thus be understood as some kind of "enactment of knowledge". "Networks" are intended to soften hierarchies, reduce bureaucracy and keep pure market effects in check. But does this not often mean concealing the truth by putting old wines in new bottles? If economisation means financial pressure on time and personnel, then the impact on the doctor-patient relationship will generally have to be assessed negatively--as is usually the case. Financial pressure is intended to provide an incentive to make use of rationalisation reserves but we have long since reached the end of our tether. The result is rationing. This means time and staff rationing and thus a direct negative impact on the doctor-patient relationship. Thinking in terms of functions with the patient viewed as a market factor does nothing to benefit the doctor-patient relationship if the doctor is compelled to give in to this line because he cannot withstand the pressure. The introduction of KIS, KTQ, RIS, DRG and Risk Management Programmes as well as clinical pathways and telemedicine has the potential to bring about an improvement of the time and staff situation if the hoped-for release of such a potential did not immediately fall prey to the pressure of costs. Currently, the introduction of all these programmes means adding to the immense burden on medical doctors, which in turn will produce negative effects on time and personnel. If the application of the working time legislation is to be observed, then the hospital doctor is threatened with becoming either a temporary agency worker or a professional holiday-maker. If the doctor-patient relationship is to be strengthened then this can only be achieved through the quality of the medical services provided and humane patient care.
Kienzle
Hans F
HF
Kliniken der Stadt Köln, Krankenhaus Köln-Holweide, Chirurgische Klinik, Köln. KienzleHF@kliniken-koeln.de
D003365:Costs and Cost Analysis; D003695:Delivery of Health Care / Q000458:organization & administration / Q000592:standards; D019317:Evidence-Based Medicine / Q000191:economics / Q000592:standards; D006801:Humans; D010817:Physician-Patient Relations; D017410:Practice Guidelines as Topic; D011785:Quality Assurance, Health Care