Medicine's changing economics have fundamentally, permanently altered the relationship between physician and patient. Traditionally, that relationship has been dyadic. Physician and patient, usually consulting only with each other or perhaps with family members, would do whatever they thought best. Until fairly recently, the physician had relatively little to offer the patient other than his 1 own personal knowledge, skill, and effort. And as new technologies emerged, third‐ party payers covered their costs, enabling the physician to continue to focus almost exclusively on the patient. These payers stood not as participating members of the relationship, but mainly as silent partners to finance and facilitate. Although the physician sometimes faced competing obligations, as for instance to other patients or to the patient's family, his professional obligation was overwhelmingly centered on each patient.
For a wide variety of reasons this situation has changed profoundly, as the physician's obligations to each patient are now embedded in a network of competing obligations and conflicting interests. Physicians can no longer deliver adequate care by using only their own knowledge and skill. They commonly must use costly technologies—an array of medical and monetary resources—that usually are owned by other people. These others, having watched their expenditures rise exponentially over the past three decades, are no longer willing to remain silent partners. Those who directly pay for health care, including government, businesses, and insurers, are instituting a broad variety of controls and incentives to ensure that physicians and patients consider the economic as well as the medical wisdom of their plans. In like manner hospitals, clinics, and other institutions that provide technologies and ancillary services are circumscribing more carefully just what facilities they will offer, to whom, under what conditions.