Power, professionalism, and patient advocacy.

A shift in the balance of power from patients and physicians to managers and administrators has caused major changes in American medicine. Physicians' professional and ethical standards as well as traditional patient advocacy are challenged by the influences of entrepreneurship, commercialism, and motivations of corporate profit. As these aspects of medical practice change, the physician remains morally and legally responsible for outcomes in an environment in which the standards of practice are established by third parties whose interest does not always represent patient well-being. In the past 2 decades, a power shift has occurred that partly explains, and is partly responsible for, the current medical climate in the United States. The balance of power in medicine in 1995 has shifted away from physicians and patients to administrators (now called CEOs [Chief Executive Officers]) and managers of everything from insurance companies to health care plans to hospital management companies. This power shift began quietly and has accelerated considerably in the last few years. The medical profession is partly responsible for the current state of affairs due to a lack of willingness to engage the administrative and political system. The excuse offered was that our job was to take care of patients, do research, or pursue whatever interest--in other words, to wear blinders-but not become involved in the messy process of running the system. Other factors driving this change have been economics, the influence of federal, state, and local governments, and the rise and general acceptance of entrepreneurship and commercialism in medicine. In addition to a change in the balance of power, there has been a change of purpose. This change of purpose of the medical system represents a transition from a commitment to provide high-quality care, often regardless of cost, to "efficient, cost-effective" health care. These changes were largely driven by economics, which has made the cost of health care a political issue. A manifestation of the current political significance of health care is the unsuccessful attempt at health care reform by the Clinton Administration in 1994 and the resurgence of interest in this issue by the q