Letters to the Editor - Feb. 21, 2000.

The physician role in primary care is slipping away - Anesthesiologists were first to establish patient safety foundation - Start a practice for $20,000? You could in 1983 - Physician freebies are also a drain on the health care system

The physician role in primary care is slipping away

Why should anyone be surprised that nonphysicians, including nurse practitioners, are being recognized as independent practitioners? With the rising costs of medical care, the simplicity of use of diagnostic technology and its increased use, as well as the advent of newer and more disease-specific medications, the real skills of the primary care physician are being supplanted.

I can easily foresee the day when primary care physicians will be only in rural areas -- if one can get them there. Primary care in the cities and suburban areas will be delivered by nonphysicians. Hospital care will be delivered by the hospitalist. Thus, the physician will be relegated in most situations to specialty care on an outpatient or office-based practice.

Sadly, we must face the fact that the medical practice of my father and grandfather, as well as the way I learned it 35 years ago, has gone away. It has been replaced by cost containment and modern technology. Hopefully, the nonphysicians and those physicians who are left in the health care system will still retain the warmth and compassion of the old days -- when we had so little else to offer -- and will not let it be totally replaced by the chrome of technology and fears of exceeding the bottom line.

--Alan S. Kaplan, MD Potomac, Md.

Anesthesiologists were first to establish patient safety foundation

Regarding the editorial "Clear message on patient safety" (Article, Jan. 17): I am appalled that AMNews could make such an error stating that the National Patient Safety Foundation was "the first national-level organization to focus on patient safety."

In fact, the approach of the National Patient Safety Foundation was based on the very successful Anesthesia Patient Safety Foundation, the APSF, which was incorporated in 1985. The AMA relied heavily on our programs to establish the NPSF. I was invited from the very beginning of planning for the NPSF to contribute our ideas and was appointed to the board of directors and executive committee.

--Ellison C. Pierce Jr., MD Founder, Past President and Executive Director, APSF Boston

Start a practice for $20,000? You could in 1983

Karen Schechter's column, "Want to start new practice? Here's a treatment plan," (Article, Jan. 24) covered the ground well and brought back memories of when I started solo practice in 1983.

It was eight months before I was able to take money home -- that is, more funds coming in than were being paid for expenses. Back then I had $20,000 to start up with an in-place furnished medical office and the landlord holding off on rent charges until I was able to start paying. I guess I had it better than most will. I retired in 1997 because the in-charge feeling left me when managed care took over.

--Cyril G. Hartman, MD Ceres, Calif.

Physician freebies are also a drain on the health care system

Regarding "Hospitals should spend more on care, less on ads" (Article, Jan. 24): As a health care consultant, I respectfully find the commentary of Michael Greenberg, MD, most cavalier. I will argue that hospital visible advertising is an important vehicle for providing potential patients access to information, product education, service options and support systems.

Though it may seem otherwise to the uninformed, advertising is a very small portion of any hospital's operating budget -- almost insignificant compared with the free meals, parking, holiday gifts, special services and the other hidden freebies doled out to medical staffs.

I know many physicians share Dr. Greenberg's feeling about advertising. Nevertheless, I would argue that physicians unnecessarily afflict our health care system with hidden costs that get passed on to patients.

I am speaking of the "gravy train" wining and dining of physicians and their office staff by hospitals and vendors. It is an all-too-common practice, if not expected adherence, that salespeople wanting to see a doctor have to buy lunch. Do not forget the physician holiday goodies and gifts. Now add the giveaways associated with physicians' continuing education.

Who will break the circle of unnecessary physician gratuities that are draining billions of health care dollars from patient care?

--John F. O'Malley Birmingham, Ala.