The Norman Rockwell image of the doctor-patient bond, typified by an all-knowing, paternalistic doctor focusing on an admiring patient, has evolved into something very different. Now it's a relationship in which patients, empowered by Internet-acquired information and buffeted by frequent changes in insurance coverage, have few qualms about challenging medical advice or moving on to the next physician. And no one has noticed this transformation more than doctors themselves.

"The doctor-patient relationship has changed dramatically with the demise of 'good ol' doc' and the explosion of medical technology," says Paul M. Ross, an orthopedic surgeon in Pawlet, VT. "Today, patients are not only more knowledgeable, they're more cynical. The increased use of physician extenders, hurried service, and overbooking have all contributed to the number of physician-patient relationships that are adversarial as opposed to collegial."

Taking care of patients still has its rewards, of course. Doctors appreciate most prominently the personal satisfactions of helping people get well and the intellectual challenges of diagnosing and treating illness. It's the rare physician who doesn't acknowledge that now, more than ever, physicians learn from their patients, and many doctors see that as a plus. Often, however, paeans about the joys of caring for patients shift into diatribes directed at the entities that physicians think are driving a wedge between patients and doctors.

Ahmet Ucmakli, an FP in Temeluca, CA, laments that "neither physician nor patient trust each other anymore. Owing to the intrusive effects of third-party payers, physicians are, at best, advisors; more realistically, we're waiters who take orders from patients, insurers, and administrators." In Philadelphia FP Brad Stoltz's view, the "constant threat of litigation" has eroded the physician-patient bond.

Physicians find some of these changes—such as the Internet-driven surge in patient knowledge about illness and health—encouraging. Still, as Charlotte, NC, plastic surgeon William Mullis points out, physicians occasionally must spend time "de-educating" patients who have picked up inaccurate information.

Here's how these factors are affecting the day-to-day practice of medicine, and how your colleagues are coping with—or even embracing—the new paradigm.

So much to do, so little time

"It used to be, 'Dr. Kamajian is my physician. Now it's 'I have Blue Cross,' " says FP Steven Kamajian of Montrose, CA. And because today's patients seem to change insurance coverage as often as aging thespians get Restylane injections, longstanding physician-patient relationships are increasingly rare. Taunton, MA, pediatrician Eric J. Ruby, who fondly remembers the days when several generations of one family came to the same physician, says that he's "sadly looking forward to retirement."

Besides being blamed for interference, insurance companies—along with regulators responsible for enforcing HIPAA, Stark, Medicare, and other rules—are seen as the chief culprits in the rushed visits that physicians and patients alike complain about. In reality, patient visits last about as long as they did before the HMOs and other insurers moved in, says Madison, WI, internist Norman Jensen, president-elect of the American Academy on Communication in Healthcare ( http://www.aachonline.org). But physician-patient face time is more limited.