To the Editor:
As a primary-care physician of 30 years who has recently retired, I read with some interest Ronald W. Dworkin’s insightful article, “Why Doctors Are Down” [May]. I am puzzled, though, as to why he exonerates the government of playing a role in creating the situation he describes.
Until 1965, the doctor-patient relationship was a consensual contract, with services agreed upon by both parties and paid for by the patient. With the advent of Medicare, all this changed. The patient no longer based decisions for care on dollars taken from his pocket, and the physician discovered that the income he received for the patient’s visit came with a growing list of restrictions on his freedom as a practitioner.
Medicare now requires an entire government agency for its administration. Its complicated regulations and mandates often compel doctors to take on additional staff, sharply increasing the overhead expenses of small medical practices. I am thus at a loss to understand Dr. Dworkin’s claim that the government has somehow “guaranteed doctors their autonomy.”
A ray of hope for the future is the burgeoning interest in medical savings accounts, which would, among other things, place the responsibility for the expenditure of healthcare dollars back in the hands of those receiving the services.
Gary D. Gillespie, M.D.
Williamston, Michigan
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To the Editor:
Adding to the picture described by Ronald W. Dworkin, I would suggest that another reason doctors are “down” is that they must walk on eggshells: any adverse medical outcome can lead to litigation, and anything less than perfection is punishable. Knowing that their decisions may be investigated, they protect themselves through over-treatment and a maelstrom of referrals.
Dealing with the medical bureaucracy has also become a nightmare. Errors in billing and violations of the new “privacy” laws have left many practitioners open to prosecution, with the possibility of severe fines and even imprisonment.
Surveys indicate that approximately one half of active physicians would like to leave clinical practice in the next five years. There is no mystery in this.
Clive Sinoff, M.D.
Beachwood, Ohio
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To the Editor:
Ronald W. Dworkin omits one important factor in the depersonalization of doctor-patient relations over the last few decades: the growth in malpractice lawsuits filed by disappointed patients. The commensurate rise in the cost of insurance has driven many doctors into group practices and managed-care facilities, which pay the higher premiums but also set rules governing treatment. In these settings, doctors are pressured by insurance lawyers to say as little as possible to patients during treatment, thus adding to the feeling that the field has become, in Dr. Dworkin’s apt phrase, an exercise in “body engineering.”
Frederic Wile
New York City
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To the Editor:
I have been practicing medicine for 50 years now, and the complaints described so incisively by Ronald W. Dworkin are similar to those I have heard.
One subtle factor that has further undermined the position of physicians is the amount of medical information that is now available to the general public. Patients come to my office daily with materials ranging from a brief news article to an exhaustive Internet printout, and then offer me advice on diagnosis and treatment. They confuse information with knowledge.
Jonas Brachfeld, M.D.
Moorestown, New Jersey
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Ronald W. Dworkin writes:
Unlike Gary D. Gillespie, I do not believe that government, in the form of Medicare, represents as great a threat to physician autonomy as managed care. Medicare may be a heavily discounted fee-for-service program, but it keeps some distance from medicine itself, allowing doctors to practice as independent professionals though at much lower rates of reimbursement. Managed care, on the other hand, insinuates itself into the heart of the medical profession, and threatens physician autonomy by getting doctors to think of themselves as “organization men” who work for higher-ups. It is managed care, not government, that employs medical directors to micro-manage doctors’ decisions, that lumps doctors, nurses, and technicians under the general category of “provider,” that promotes flex time and shift work, and that accustoms doctors to the idea of advertising. Government only threatens doctors’ incomes; managed care forces them to change their very mindset.
Clive Sinoff and Frederic Wile are correct to note how troublesome the practice of defensive medicine is for doctors. But I do not believe that the cost of malpractice insurance was an important factor in the rise of managed care. As it happens, malpractice premiums stabilized during the early 1990’s (in my own specialty of anesthesiology, they even began to drop). Doctors were compelled to join managed care not in order to get their insurance premiums paid but because managed care had the patients. As business turned to managed care to control rising costs, doctors had to join to stay in practice.
Like Jonas Brachfeld, I, too, have dealt with patients armed with just enough medical information to be dangerous to themselves. If being the sole interpreters of a complex art once enabled doctors to perpetuate the mystique surrounding the medical profession, the democratization of information has assuredly contributed to a decline in this mystique, and hence in the professional ideal itself. That ideal now finds itself under the twin threat of capitalism (in the form of managed care) and democracy—another reminder of the historical origins of the medical profession in premodern ideas of service.
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