A Physician Who is Accessible, Attentive and Respectful Will Form a Relationship That Withstands the Influence of Change

James B. MacWhinney, M.D.

James B. Mac Whinney was born in Summit, NJ, and attended Princeton University. After graduation from the U of R School of Medicine and Dentistry, he served as a rotating intern at Ohio State University. Following internship he completed a 2-year tour as a flight surgeon in the U.S. Air Force and then returned to Rochester for pediatric training and a hematology fellowship. As assistant clinical professor of pediatrics at the University of Rochester Medical School, he practiced general pediatrics with the Panorama Pediatric Group for 38 years, retiring in 1999.

In the face of major changes affecting pediatric practice over the past four decades, the relationship between pediatrician and patient remains a constant. It is a relationship that depends on physician behavior and attitudes. A physician who is accessible and attentive and respectful will form a relationship that withstands the influence of change.

The changes that have affected the health of children have been substantial. Some change has resulted from scientific discovery and some from alteration in the area of delivery of care. An example of an important scientific advance is the development and use of vaccines. Polio has been eliminated in the U.S. and measles, mumps, varicella, pertussis and disease caused by H. influenza B are rarely encountered because of immunization.

Changes in the way care is delivered have also been notable and some of these changes can affect the physician-patient relationship. Changes in the delivery system include such things as practice size (patient population served), staff size, place (office vs. home), payment policy, on call (coverage) policy and malpractice issues.

Most practices start small and grow, as ours did. We started out with three pediatricians and one nurse (who did everything) and grew to our present size – seven pediatricians, four nurse practitioners and about twenty in support staff. Early on we made house calls all morning and again in the evening; now we rarely go on house calls. Thirty-five years ago payment was on a cash/fee for service basis ($8.00 for a house call); now the majority of our patients belong to an HMO, which pays the fee (minus co-pay and risk amount). In the early years we answered phone calls as they came in, interrupting a patient visit to respond to a non-urgent call; now we have trained triage receptionists who field those calls and interrupt us for emergencies only. We now also use a nurse triage service at night, which provides advice and refers to the doctor on backup call when necessary. In the early 60s malpractice insurance cost less than $200/yr. That changed, as we know. In the early days a referral was made to a consultant of choice; now we are gatekeepers and must refer to a limited panel and obtain approval from the HMO before the consultation takes place.

These alterations in the delivery of care, some of our own doing and some imposed by the HMOs, could lead to a significant disruption in the doctor-patient relationship. It's our call. We can't blame the government or the HMOs. If we continue to work at being accessible to our patients and to listen attentively and to regard them respectfully, the relationship will endure.