Talking with an insurance doctor, who denied a vertebroplasty for my patient with a spontaneous compression fracture, I started thinking about the dilemma of defining what a doctor-patient relationship is.

A couple of years ago a local doctor with a dwindling private practice joined an Internet medical site that promoted drugs like Viagra and offered online consultations with physicians who prescribed the medications when they felt it was appropriate. The state medical board disciplined the doctor with a warning, a stiff fine and a permanent blemish on his record.

The charge was prescribing without a physician-patient relationship.

It struck me as ironic that providing a treatment long distance gets you in trouble with the medical board, but denying treatment to patients you have never met or communicated with in any way is perfectly acceptable. It might even qualify you for a bonus?

The managed care industry, on its own, redefined the doctor-patient relationship many years ago, and now the Internet and the government are continuing the transformation.

In 1999, writing about the inherent conflict between being someone’s doctor and in reality also working for the insurance companies, Goold and Lipkin conceded that the doctor-patient relationship is still something very personal:

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