• C Alex.
• Gesundheitswesen. 1994 Feb 1; 56 (2): 103-6.

AbstractThis article concerns the rules and regulations governing the Federal German compulsory (statutory) health insurance which, among other ordinances, define the tasks of a so-called "Medical Service of the Statutory Health Insurance". The definitions given under the heading "Expertizing and Consultation" create a field of tension between the activities of advising the insured patient on the one hand and giving an expert opinion to the insurance body on the other, both functions being exercised by one and the same doctor. Four examples from daily practice are given to illustrate this, each example covering a different kind of medical activity. Against the background of his job to prepare an expertise for the insurance body the doctor confronts the insured patient: in the first example, he has to examine whether the kind of medical care for which the insurance body must pay is feasible from the cost viewpoint (or to suggest an alternative, cheaper method); in the second example, he removes well-founded doubts regarding the patient's inability to work, at the request of the employer; in the third case, he examines a prescribed or desired medical treatment or cure, and in the fourth case he examines the need for an adjuvant or remedial measure before this is sanctioned by the insurance body. These case reports show that there is no contradiction between consulting and expertizing: the results of expertizing can be conveyed to the patient in a comprehensible manner only by advising the patient accordingly. The expertizing doctor is no longer anonymous when he gives advice to the patient, and this is a challenge--in respect of competence, human understanding, and ability to face and resolve conflicts.

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