AMA Young Physicians Section took a leadership role in the fight against limiting hospital privileges
Regarding "AMA: Limiting privileges hurts patients"
(AMNews, March 6): I was thrilled to see that the widespread practice of closing medical staffs and limiting privileges by some hospitals has finally made it to the front page of American Medical News.
I am also glad that the AMA has at least taken a limited position to try to correct this. I am disappointed, however, that more mention was not made of the struggles of the AMA Young Physicians Section to combat this practice and that the broader issue of limiting privileges by so-called "medical staff development plans" was not addressed.
For the past several years, the AMA-YPS has been trying to bring this issue to the AMA for appropriate action. Finally, at the 1999 Interim Meeting in San Diego, we were able to pass a resolution that asked the AMA to "study the impact of medical staff development plans on physicians entering or changing practice; and delineate under what circumstances these plans may be illegal restraints of trade under the antitrust laws."
The ability of young physicians and physicians just out of training to practice where they choose is severely limited by these plans. Over the years of trying to debate this issue within our own section and on the floor of the House of Delegates, we've heard many egregious cases like those mentioned in the article.
Further, there were just as many, if not more, cases in which the motivations for keeping medical staffs closed seem to be to protect the current medical staffs, more so than the hospitals, from competition by the new applicants.
In fact, over the years the major resistance to the YPS initiatives in this area has come from physicians who are on the other side of the fence from us. Physicians who are already in practice and have established themselves have nothing to gain by opposing a close medical staff offered under the guise of maintaining a financially healthy hospital. They, in reality, are often the biggest winners in this game. They cannot be threatened by a practice that is expanding from a nearby hospital. They cannot be threatened by a resident or fellow fresh from training who wants to move into the community. They cannot even be threatened by the kid who wants to come back and practice in his own hometown.
--Christopher M. Hughes, MD
YPS Delegate, Monongahela, Pa.
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Hospital privilege restrictions keep patients from seeing doctor of choice
The article regarding hospital privilege restrictions
(AMNews, March 6) is but the tip of the iceberg. Hospitals have forced their choices for anesthesia, radiology and emergency department staff for years on community physicians. While patients may be able to choose their physicians, those physicians frequently cannot choose who will provide care in the hospital itself.
Hospitals may place themselves in a position of favoring one group over another. This can be under the excuse of inadequate facilities for additional practitioners, or by mandating that a third party accept the new physician for privileges to be granted. This is usually a backroom, "good ol' boy" tactic to promote one group's agenda at the expense of the community as a whole.
Arbitrary restrictions on the location of a primary office is used to deny patients care in their hometown, forcing them to choose a local physician or travel out of town. As local employers penalize patients who do not use the employers' preferred hospital, where discounts have been extracted below operating cost, patients pay more for potentially lower quality care.
Physicians must protect their patients' best interests, while recognizing the difficult position of their hospitals. The inadequate reimbursement provided by Medicare and Medicaid forces hospitals into unethical practices as a means of survival. This should not be acceptable to the medical community or the public at large.
--Jeffrey W. Byrnett, MD
Burlington, N.C.
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Consultant got it all wrong about physician "gravy train"
Regarding "Physician freebies are also a drain on the health care system"
(Letters, Feb. 21): The following is a rebuttal to [Birmingham, Ala., health care consultant] John F. O'Malley's letter to the editor published in AMNews. It is quite irritating when a nonphysician criticizes physicians without fully understanding the issues and presents a one-sided version of the story.
As a practicing physician, I am appalled by O'Malley's insinuations that physicians are draining billions of health care dollars riding a "gravy train" of unnecessary physician gratuities provided by hospitals and vendors.
Firstly, I would inform O'Malley that there are fairly stringent laws that exist to prohibit exorbitant spending by hospitals on physicians.
Secondly, I consider free parking, meals and assistance with CME a considerate gesture on the part of the hospitals for the time and expertise that is donated by the physicians serving on the numerous hospital committees that exist to improve the care provided to patients in that community. Countless hours are also spent throughout the year, albeit in increments of five to 10 minutes, by physician education of nurses at the bedside, thereby further advancing their knowledge and allowing improved patient care.
This activity has increased significantly over the past few years due to the increased nursing turnover caused by the current changes in the health care field that have resulted in newer, less experienced nurses being hired. I would also point out the fact that most physicians on staff take call without pay providing care for the indigent that invariably seem to arrive during the night with a problem that has long been ignored and on occasion with unrealistic expectations that ultimately increase medicolegal expenses. These common activities provided by physicians clearly benefit the hospital and, in turn, society, where the financial tradeoff more than offsets any money spent on parking, meals and CME.
As for his comments about vendors who bring meals for lunch to speak with physicians, that does not occur in my office. But I believe this is a voluntary effort and would interpret this as the cost of doing business for these vendors trying to sell their product.
Perhaps if there were more space and time, several other significant issues that affect the health care system and the physicians that O'Malley has criticized could be addressed. I would have to believe that there are a handful of physicians who have benefited a great deal and have taken advantage of the system; however, the majority of physicians do not fit into this category. O'Malley owes an apology to these physicians who have been offended by his thoughtless and detrimental comments.
--Mark E. Sutherland, MD
Texarkana, Texas
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Examine credibility of Institute of Medicine report on patient safety
I have read most of the Institute of Medicine report [on patient safety] and, as expected, found that there is little detail on what was considered a death due to medical mistakes. What is clear is that the report extrapolates from a small number of patients to the country as a whole.
Having been in practice as a cardiologist for 28 years caring for critically ill patients, I think if we were responsible for up to 100,000 deaths per year due to medical mistakes I would be able to remember at least one case. Like everyone else, I have been aware of mistakes in doses and types of medications; however, these are rare, and I can't remember any of them resulting in the death of the patient. Our hospital has a system to review all mistakes and follows through with changes to avoid further mistakes. I doubt if we are any different from other hospitals in this country.
Clearly, before we accept the results and conclusions from the Institute of Medicine, the individual cases should be reviewed again by an independent group. We have had other supposedly legitimate studies that on critical repeat review were found to be a gross exaggeration of the truth (i.e. the connection between breast implants and rheumatolgical diseases). How do we know the same won't be found here?
In the meantime, we suffer the loss in confidence of our patients and their families; and who knows what effect that will have on the already excessive litigious state of this country's health care.
--Charles E. Hansing, MD
Bellevue, Wash.
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Physicians should stop taking on role of drug plan administrator
Re: "A 37-minute lesson on how health plans should not handle a call"
(Letters, Feb. 14): I read with interest, anger and discouragement the letter by Jordan Goetz, MD, regarding the time spent on getting authorization for a certain medicine. This is the kind of thing we all need to stand up against. By thinking we are doing the patient a "favor" by doing this, we are taking away time and/or money from patient care and decreasing the quality of care.
We must stop prostituting ourselves like this. All doctors must stand up and say: "I'm a doctor, not a drug plan administrator!" In my office, I tell patients exactly this. I refuse to get involved in "preauthorization" of drugs on formulary. I am simply there to give the patient my advice, expertise and prescriptions, not to administer their drug plans.
The more physicians do this, the more demanding HMOs become. Dr. Goetz, you do have a choice -- you can say no, which is what we all need to say to things HMOs do to slow down care.
In my dermatology practice they are "requiring" this for certain meds, knowing we do not have the time or staff to do it. These are services not covered under the contract, so it lowers the expenditure for the company.
Stop doing everything the HMOs tell you to, and you will help all of us out. The more you do these things, the worse it gets for us all.
--John Cottam, MD
Tampa, Fla.
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