"Ethical Imperatives and the New Physician: II. The Physician-Patient Relationship" [Reminiscence]
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Koop, C. Everett
Reproduced with permission of C. Everett Koop.
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Ethical Imperatives and the New Physician: II. The Physician-Patient Relationship: Presented at the Sesquicentennial Commencement
Exercises of Albany Medical College, Saratoga Springs, New York (May 26, 1988)
Ethical Imperatives and the New Physician: II. The Physician-Patient Relationship
Commencement Address by C. Everett Koop, MD, ScD
Surgeon General of the U.S. Public Health Service
U.S. Department of Health and Human Services
Presented at the Sesquicentennial Commencement Exercises of Albany Medical School
Saratoga Springs, New York
May 26, 1988
I gave the Commencement Address at Albany more than once and it's a very interesting commencement indeed. I know of no
other that is more family oriented and it was such a joy to see proud mothers and father hooding their own children. The students
marched in to their seats between two lines of faculty and the faculty exited between two lines of students. The warmth between
students and faculty was apparent and the bagpipes didn't hurt a bit either.
I congratulated them on 150 years and told them how impressed I was by anything that worked that long, especially that medical
school. Early on, I got into the theme of the day by calling their future careers a "vocation', because of its root
term of "calling". That is because the practice of medicine is an activity with a firm moral base. I then announced
I wanted to spend the time I had that day looking at one of the most transcendent issues of medical practice and sharing my
perceptions of what it has meant to me. I mentioned in passing the cycle of addresses I was giving that spring and that they
would receive all of them in a bound copy during the summer. Today, however, I would confine my remarks to what is commonly
known as the doctor-patient relationship.
I began by telling them a little about my background and how long I had been in medicine, but acknowledged that the most impressive
change of all, had taken place in the metaphysical experience we call the doctor-patient relationship. It began with the decline
and virtual disappearance of medical paternalism - "the physician-father knows best". That goes for the "physician-mother"
as well. I reminded them and hoped that they would understand for themselves that a physician is not a "provider"
and my patients were not "consumers". My terms carry the implications of a personal relationship - something that
is confidential and trusting. I urged that whatever that class called them, to invest them with the feeling of personal involvement
that has been the hallmark of responsive medical practice for centuries.
Today, physicians are more inclined to be open and honest about their uncertainties. That's one of the origins of the
"second-opinion". This "new humility" could be quite becoming. Accepting one's own human fallibility is
really a strength, not a weakness and I was happy to see that physicians have come to agree with that point of view. Although,
maternalistic and paternalistic medicine may be fast disappearing, it has not yet been replaced with a single ethic with the
same simplicity and power. If anything, we're evolving into a "physician-patient partnership". In such a partnership,
the patient has a right to know, then armed with this knowledge, be in on the final decision-making process regarding therapy.
I then discussed some of the pros and cons of the old and the new relationships. But whether one will treat patients as a
partner or in loco parentis, one naturally must maintain the professional right and the obligation to manage the patient the
way one thinks is best. I pointed out the pitfalls of moving in one direction for over-treatment and in the other for under-treatment.
In general, I have found that the "take charge" type of relationship with patients usually comes from physicians,
more concerned about the "sanctity of human life", because they do in fact see themselves as the ultimate guardians
of other people's lives. They take that role very seriously.
Then, there is the tendency that may appear with that philosophy to do absolutely anything to save the life of a patient,
to extend the process of dying under the guise of doing heroic and extraordinary things.
Another question that arises in the physician-patient partnership is the inability of some patients to be partners, because
they are profoundly dependent. I got a little personal here and revealed that I always tried to gain, as my allies, the parents
of each of my young patients. I need more than just their informed consent. I needed their informed love and concern and energy
so that we could fight - together - the particular anomaly or disease that was threatening their child. Win or lose, we always
retained that sense of partnership. Could that be the reason - totally unanticipated - that I was never once sued for malpractice
in a surgical career that spanned 40 years?
I then discussed the "academic ring" that some of the things I said must have and how these kinds of questions have
always been percolating in the consciousness of medical practitioners, which got me into the subject of medical specialization
and group practice arrangements. I spoke of the advantages of such, but lamented the fact that the trade-off for such progress
was that few physicians today get to know the whole patient, as well as their predecessors did. I introduced the fact that
some patients prefer less dependence and more right to privacy and the freedom to pick and choose. This tension between parental
medicine and partnership medicine is being tested now across the board in our profession. The sorting out process is far from
over. I gave some examples.
I closed with assuring my young audience that there is life after medical school and reminded them that many of them would
help bring about the changes that lay in the future. I relayed my confidence that the physicians of America will emerge from
this time of ferment with a stronger ethical framework within which to practice a type of medicine that serves the needs of
informed and involved patients.
I quoted my old friend, Dr. Edward Pellegrino of Georgetown who said, "Some degree of effacement of self-interest is .
. . present in every medical oath, that is what makes medicine truly a profession." For myself, I said that I hoped that
my reputation for straight talk was lived up to that morning, but that it hadn't dampened my enthusiasm for medicine.
If I could do it all over again, I would join them at the start of a magnificent career.