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a Hippocratic view of workers, employers and insurers

Who complicated the doctor-patient relationship?

Did we somehow complicate clinical relationships in the 20th Century?  No, we did it quite earlier.  Two and a half millennia ago in his First Aphorism, Hippocrates quite purposely implies third parties may have a strong effect on the processes of diagnosis and treatment.  (In the translation of W. H. S. Jones, "Life Is short, the Art long, opportunity fleeting, experiment treacherous, judgment difficult.  The physician must be ready, not only to do his duty himself, but also to secure the co-operation of the patient, of the attendants and of externals."1 My own loose translation, "Life is short, the art intricate, experiment slippery, decision hard to come by.  The physician must be ready not only herself (or himself) to do what must be done, but also to engage the patient or any outsider--even third parties.")

By “third parties” (or the equivalent thereof, exothen in Greek) did Hippocrates mean the same as we do by “third parties” or, as we often say, third party payers?  Yes, substantially so.  Although the language of the aphorism may seem to refer to those who are immediately present, there is no difference in effect if the third party is geographically distant.  Today, everyone is present to the occupational clinic by fax or phone.  It is foolish to assume that the closed door to the examining room hermetically seals off the clinical interchange.  Hippocrates made no such oversimplification, admitting in his very first aphorism that others will be present who can help (or hurt) in the care of the patient.  He sees it as the physician’s task to orchestrate all resources, effectively to engage all parties in a constructive rather than in a negative or negligent fashion

Hippocrates seems to have offered his diagnostic and therapeutic skills for the sake of the person who was sick, often household slaves who did not have high levels of social status or resources.  Their masters paid the fees, perhaps, but could the master dictate processes of diagnosis or treatment?  Could the master dictate that the slave must perform particular tasks beyond her or his physical capacities or in such a way that it would prolong or intensify suffering or disability?  Probably not; I get the sense from several Hippocratic texts that Hippocrates and his followers focused on the condition and welfare of the patient, looking to enhance cure for the patient’s sake.  Disciplined study of anatomy, pathophysiology and epidemiology were aimed primarily toward the recuperation of the sufferer.    It is implied that the benefit of others would follow if the patient could recover.  Could the master, hypothetically, dictate the administration of lethal doses of poison to avoid an expensive or prolonged treatment?  Certainly not.

All Greek texts, those of Hippocrates himself and those quite clearly from different times, hands and minds, focus on processes of diagnosis, treatment and prognosis, especially on manifestations of disease (their natural history and pathology).  There are some metaclinical commentaries on the social context of the practice of medicine (such as this First Aphorism and the famous Oath, which is not Hippocrates’ work at all, but about 200 years later).  Not one word indicates that a master or father or husband could dictate or terminate treatment despite male citizens’ dominant social and economic status.  Clinical recommendations for action (judgment) appear to have been the responsibility of the physician.

Whose interest should be served?

The First Aphorism helps me see that the primary benefit is meant for the patient, then “trickles down” to the other parties.  That is the assumption we usually work from (though too often we are not rigorous about benefit assessment).  And the First Aphorism gives me a closely related corollary, that the attitudes and actions of third parties may make an important difference in outcome, so it is the physician’s task to engage them effectively. 

We have taught and learned medicine as if the patient lived in a vacuum.  The establishment of Family Practice as a medical specialty during my own career contradicts that, showing that clinical enterprise is anchored in conscious consideration of the context in which the patient lives, suffers and recovers. Occupational medicine has become titled “occupational and environmental medicine” by no accident, but by the realities which inform Hippocrates’ work (not only reflected in the First Aphorism, but addressed in detail in his several epidemiologic works). 

Contemporary practitioners who do not specialize in occupational medicine may not be practiced at considering the patient in the work environment; they may be reluctant to communicate openly with third parties.  As Hippocrates pithily implies (in the condensed power of the aphorism), such communication is not so much a report as a dialogue:  the clinician does not simply render up facts to the powerful payers, but engages them better to understand and cooperate with, even help to refine the clinical recommendations, not only for the sake of the patient but for their own benefits.  Legal applications cascading from the Americans with Disabilities Act reflect this broader involvement of the employer and the employee in decision making:  the clinician consults and advises, but hiring does not depend on examination by the clinician nor is the clinician directly responsible for the choice of appropriate accommodations for disability.

The clinician who limits communication in the occupational setting may tend to withhold information self-righteously, assuming that one who reports fully must have sold out to the insurers and employers.  Without understanding clinical relationships physicians may assume there should be a secrecy in the clinical communication.  They may claim confidentiality is for the sake of the patient, but really use that as a myth to enhance their own egos or to maintain power through secrecy, or even to hide their own clay feet, their own faulty processes of diagnosis, treatment or bookkeeping, to avoid scrutiny or regulation.

Certainly in Hippocrates’ time there were mercenary quacks among the Greeks who would curry the favor of the powerful and wealthy, but we possess none of their writings to suggest how to become toadies to moneyed interests or politicians (and we would be embarrassed to write or speak aloud that way today). The clinical behaviors of “company doctors” can be as destructive of good results as are those of the self-righteous self-appointed secretive “priests” who withhold information.  Physicians who believe their job is to take the side of the employer or insurer make reports to curry favor, not recommendations to improve health; they act like tattle-tales (social and emotional misbehavior we learn to eschew by the second grade).  On the other hand, those who withhold or obscure information as if out of “loyalty” to patient confidentiality reflect misunderstanding of the three-party nature of the clinical relationship, flattening it into two dimensions of patient and clinician alone (simpler, but not realistic); it is as if their view lacks depth perception, so it will be better not to let them land airplanes or defuse bombs.

If we choose a Hippocratic model, we will give priority to clinical issues over political (marketing) issues, and we will give priority to patients’ interests over employers’ if there were any real conflict of interest between them, but there is not.  In order to clarify any confusion about conflicts of interest between parties in the clinical relationship, I assume the best outcome for all parties is the best health of the patient.  So, my own first aphorism of occupational medicine acknowledges that ultimately there is no discord between the interests of the different parties.  I am not sure when and how the assumption became crystallized in clinicians’ minds that the employer is against the worker, the worker against the employer or both against the insurer.  To assume there is polarization rather than consonance of values can only be counter-productive.

We have plenty of problems; just what is the solution?

Just as the clinician can misunderstand or pervert values by purposeful or inadvertent misbehavior, so can the other parties.  It is the clinician who has responsibility to be aware of ethical and practical realities, at least in what I describe as a Hippocratic viewpoint.  The laws of most states do not yet acknowledge that corporations have become much larger and louder than individual practitioners; malpractice codes still hold the individual licensed practitioner responsible for outcomes over which she or he may have little influence.

Insurers who deny claims and withhold payments; claims managers who deny approval for tests or treatments, or even withhold cab fares to get to them; employers who refuse to accommodate restrictions; and workers who use illness or injury as tools for resentment or revenge or who try to support themselves financially by being hurt rather than being productive—all these are acting as short-sighted pinch-pennies, no doubt; but they do it out of ignorance.  They multiply expense and suffering, precipitating the involvement of attorneys as fourth parties for litigation or legislation, non-clinical processes which become huge unanticipated burdens on the first three (clinical) parties.

I see the patient’s role and responsibilities in the occupational setting as no different than in any other clinical application:  The patient’s primary responsibility is to be willing to be well; she or he can be self-defeating for a number of reasons, but it is the clinician’s task to see and to discuss obstacles to health in dialogue with the patient sensitively and effectively.  If we acknowledge what Hippocrates implied two and a half millennia ago, we see the worker is injured or ill in a context of persons (including family as well as persons in the workplace), roles (not defined by job description alone), risks (including substances and machinery which are not designed for her or his physiology or comfort), fears (which she or he is afraid to acknowledge or express), expectations and the effects of past experiences, the product of all of which we must respect and respond to simply and openly in order to engage the patient in her or his own recuperation.

Sometimes we are puzzled that we have so little control over the outcomes of our treatment efforts. Often we see stubborn delays which we cannot easily redirect or re-energize even though we may have seen clearly some of the obstacles to recovery.  We may have seen signs of those identifiable obstacles at the very first encounter (e.g., deconditioned state of the musculature, anger manifest toward the supervisor, confusions in communication among the parties, symptoms which by their non-physiologic conformation warn of complicating factors). Occasionally we see a patient recuperate more rapidly and thoroughly than we imagined possible; human persons are dynamic:  sometimes we see changes in the clinical course which we cannot easily explain, for instance a patient who seems to have floundered may suddenly get well because of unusually strong constitution or personality, or perhaps because non-clinical factors have changed (e.g., threat of job loss, perceived need to return to full duty for the sake of income to support the valued family).  Diagnostic labels help us little to predict the course of recovery in any real case (even though insurers make all their arbitrary decisions on the basis of diagnosis codes).  (E.g., we cannot exactly predict the course of a case of medial epicondylitis, even if we engage a psychological consultant).

Hippocrates has set a good precedent, to consider all aspects of the patient and of the environment broadly, not to founder in narrow blindness or arrogance (e.g., unexamined blind faith in textbook protocols).  It is the clinician’s task to educate all three parties (the clinician and clinical team, including bureaucrats of our own organizations; the patient and those attached to the patient, including family and coworkers; third parties who have a financial interest in the patient’s health, including employers, insurers, and regulatory agencies). We need to facilitate and to participate in shared understanding in simple practical terminology based in mutual benefit for all parties, rather than outmoded ex cathedra pronouncements in code or in technical mumbo-jumbo.  Perhaps we need not engage or educate fourth parties, those involved in adversary relationships quite alien to the clinical harmony which seeks only health of the patient. 

To educate these three parties to the clinical relationship is an arduous task; indeed “life is short, the Art long...”.  As a physician I am bolstered by two moral models besides my teacher Hippocrates:  the grandmother, always knowledgeable, powerful and benign (I am convinced men become doctors as a poor compromise because they cannot themselves become grandmothers); and the second grade teacher (who repeats each part of each lesson for each student patiently day by day, never seeing except by faith the end result of his or her effort). 

Then, to engage and educate third parties is a responsibility we cannot evade, so we may as well do it as Hippocrates would have us do our other tasks:

The course I recommend is to pay attention to the whole of the medical art.  Indeed, all acts that are good or correct should be in all cases well or correctly performed; if they ought to be done quickly, they should be done quickly, if neatly, neatly, if painlessly, they should be managed with the minimum of pain; and all such acts ought to be performed excellently, in a manner better than that of one’s own fellows2.


1 Hippocrates, translated by W.H.S. Jones, Loeb Classical Library, Aphorisms, Vol. IV, p. 99, Harvard/Heinemann.  Hippocrates wrote the Aphorisms quite directly and purposely, especially the first ones, formulating them carefully in his old age, selecting their order exactly.  This first aphorism, then, must be his most cherished nugget.

2 op. cit., Regimen in Acute Disease, Vol. II,  p. 65.

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