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The hot colour OF MEDICINE
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Additional resources for Harrison's Principles of Internal Medicine 16th Edition
Economic Incentives Economic incentives are closely related to the other two categories of practice-modifying factors. Financial issues can exert both stimulatory and inhibitory inﬂuences on clinical practice. In general, physicians are paid on a fee-for-service, capitation, or salary basis. In fee-for-service, the more the physician does, the more the physician gets paid. The incentive in this case is to do more. When fees are reduced (discounted fee-for-service), doctors tend to increase the number of services billed for.
Patients often provide information that “does not ﬁt” with any of the leading diagnostic hypotheses being considered. Distinguishing real clues from false trails can only be achieved by practice and experience. A less experienced clinician who tries to be too efﬁcient (as in the above example) can make serious judgment errors. Furthermore, the value of conducting a rapid systematic clinical survey of symptoms and organ systems to avoid missing important but inapparent clues cannot be overstated.
How much is told should depend on the individual’s ability to deal with the possibility of imminent death; often this capacity grows with time, and, whenever possible, gradual rather than abrupt disclosure is the best strategy. A wise and insightful physician is often guided by an understanding of what a patient wants to know and when he or she wants to know it. The patient’s religious beliefs may also be taken into consideration. The patient must be given an opportunity to talk with the physician and ask questions.