Dr Alper is a practicing internist in Burlingame, Calif, and a Robert Wesson Fellow in Scientific Philosophy and Public Policy, Hoover Institution, Stanford University, Palo Alto, Calif.

When I was growing up in medicine, advocating for the patient was considered a normal part of medical practice. Internists, as quintessential “personal physicians,” viewed effective and comprehensive patient advocacy as a cardinal characteristic that set internists apart.

Those of us in training during the early 1960s, before limits were set on intern and resident hours, were largely disconnected from the iconoclasm and ideological chaos that soon convulsed the country around us and permanently reset many norms. Our patients occupied us to a degree that left little room for grandiose social experimentation.

So square was I when I became an attending physician at San Francisco General Hospital later in the decade, that I was positively discombobulated by the tieless, rumpled, unshaven house staffers who took off their shoes during chart rounds and, in one instance, propped a pair of stockinged feet on the table in front of me. What about respect, I ­wondered? Would I want doctors like these to treat me and be my advocates if I were a patient?

Events overtook any qualms I had when the interns and residents went on strike, on behalf of better patient care, they proclaimed loudly in the media (and, as a seeming afterthought, for a house staff pay raise). This new wrinkle in patient advocacy, coercive and manipulative as it was, was designed to shake up the system, if not overturn it. I say “coercive and manipulative” because of the strike and the spin. Who can deny that a pay raise for the house staff might also improve patient care?

Single-issue politics has generally changed the face of advocacy in the United States. Whether it is on behalf of treatment for a particular disease, for the homeless, or to claim compensation for wrongs experienced by a particular social or employee group, advocacy has become strident and disconnected from any concern with competing social goods or practical limitations. “Getting the message across” is paramount.

Patient advocacy changed apace. The quiet and genteel advocacy of the past meant knowing the health care system, who did what best, and being willing to intercede and even bend the rules on behalf of patients. Try to imagine calling colleagues to give a break to “poor but honest” patients. Billing has become so automated, contracted, and subject to fraud and abuse provisions that this common practice, if not already obsolete, is becoming so.

There was a downside to the good old days. If doctors could give breaks to patients, it was only because they were relatively free to set their charges as they alone saw fit. Patients had little to say about fees, and it was difficult to shop for better prices. Insurance carriers, on the other hand, complained that doctors lied about diagnoses to secure coverage that exceeded contractual limits and that even if this was done on behalf of patients, it was also of direct benefit to the physicians who provided the services. (A number of surveys showed that, at a minimum, stretching language and presenting information in ways likely to improve insurance coverage met with greater acceptance among physicians than protecting the insurance carrier’s interest.)

Enter the health maintenance and preferred provider organizations. Most were sponsored by insurance carriers, newly gussied up as patient advocates. Pur­chasing agreements with providers that guaranteed discounted in-network care were popular with patients. And because far more people run into fee levels upfront as opposed to having to deal with contractual limitations on services, the downside lay beyond the horizon. But it came. The “managed care backlash” was inevitable. A steady switch from nonprofit to for-profit structure, huge executive salaries (even by industry standards), and soaring profits were extensively covered in the media and eroded the moral gloss that originally sold the product. In addition, over time more and more patients encountered restrictions on covered services that were now clearly in competition with the carriers’ bottom line and that of their executives.

The carriers adapted. The language of advocacy is still heard, but in much more muted tones. There are now fewer denials but much more cost-sharing by patients. A kind of blame game is being played, in which all parties that fund care try to pin the tail of blame for high costs and especially for “poor value” for the dollars expended on someone else’s donkey. This includes government, the source of roughly half of all health care expenditures. The salience of dollars is currently competing with campaigns to improve the quality of care, both by decreasing errors and by greater adherence to accepted clinical guidelines. This has real commercial appeal, be­cause demands on providers of care are imposed before compensation catches up. Thus, it is a good deal for carriers and for patients. Once again, advocacy and a reassertion of the moral high ground.

Many other parties vie for the title of patient advocate. The Institute of Med­icine, the news media, the American Association of Retired Persons, and other consumer groups are just a few examples of vocal parties that reiterate the insurance carriers’ and government’s message: namely, you have very little reason to believe your doctor will do right by you either clinically or financially without the kind prodding that we provide. The corollary is that without us, you are lost. And if that wasn’t enough, the voices clamoring for a single-payer health plan for the United States amplify the message by adding that the system itself is so broken, it can’t be fixed. They anoint themselves as the ultimate patient advocates.

Enter now the empowered patient, the focal point of all this energy expenditure. Owing to the Internet, available to two thirds of Americans, according to a recent Pew survey, savvy patients go forth to do research on their own now and come to the doctor armed with long notes detailing their own preventive and therapeutic strategies. We’ve all met patients like these. Some have refined the notion of what they want to a single organ. For example, 2 young women, self-referred for suspected thyroid problems, recently balked when I asked to examine more than their thyroid glands, just to be reasonably sure that no other undiagnosed medical problem was contributing to their symptoms. Here indeed was a place for patient advocacy…by the doctor. One woman remained too sus­picious of my motives to even listen. Ultimately, I told both that thyroid glands do not exist in a vacuum and to also get a general physical…at an office of their choosing. (By the time the second patient wanted me to do one, I had no time left to do it.)

Our physician role as patient advocate has been so sliced, diced, and subject to criticism that it is hard for me to describe it even to myself in meaningful terms. Nor has reading helped. Arnold Relman, MD, former editor of the New England Journal of Medicine, still believes physicians should pretend that money does not exist when caring for patients (his book on the subject is due out shortly). At the other extreme, James Hardee, MD, a Kaiser Permanente internist in Colorado, believes that physicians should delve deeply into economic issues of care with patients (See: “My Doctor, My Friend, and Now, My Financial Adviser.” Denver Business Journal, December 12, 2005).

The single event that taught me what I most needed to know about patient advocacy occurred in my own office in my fifteenth year of practice. My teacher was my office manager, who, together with a registered nurse who worked with us, believed that putting patients first and going an extra mile on their behalf also included letting the doctor know when he transgressed. Apparently patients had been complaining about my ill-humor for several weeks.

I had not realized that I was becoming irritable and impatient. One day I responded to a chronic complainer on the phone neither rudely nor brusquely, but shall we say, unsympathetically.

As I hung up, my assistant, who had overheard me, reddened and blurted out, “They’re your patients. And they deserve your best!”

What she said was not very boss-friendly. But it was patient-friendly. And that really is more important. I never forgot it.

There can be many patient advocates; however, physicians need to be first among them.