Letters to the Editor - May 8, 2000.

Pay issues must be addressed honestly in health system debate

As a practicing physician of almost 10 years, I have seen the emergence of managed care and the resultant anxiety it has caused many of my colleagues. I would like to make the following observations.

Doctors are, by and large, a highly intelligent group of people who entered this profession because of a love of the biological sciences, an appreciation of the "art" of medicine, a desire to make patients and ourselves feel better through the practice of our profession and a desire to be well-reimbursed for our services.

It is on this last point that many are afraid to speak out for fear that our profession will somehow be diminished if the public feels that money is one of the driving forces in choosing this profession.

The fact is that this country holds out the promise of financial rewards for those who are willing to sacrifice much or all of their personal life in order to advance their professional life and sharpen their skills.

This sacrifice is a prerequisite for the medical profession.

What is happening now is the paradox of public expectations of higher quality with concomitant shrinking reimbursements.

This is resulting in doctors feeling that the system is operating off their backs.

The net effect is that doctors must increase their productivity (such as seeing more patients in an hour or using "physician extenders"), and/or formally develop a first-class level of service, to keep their incomes from plummeting.

For the typical patient, quality must decrease because the single most important factor in timely and accurate diagnosis is allowing adequate time for the physician to speak and examine a patient.

Until every one of these issues is discussed openly and intelligently by those with open agendas, the future of our country's health care system seems destined to founder, with occasional great successes and spectacular failures.

--Steven M. Adler, MD Rockville Centre, N.Y.

AMA should stay away from technology ventures

I have been an AMA member for almost 20 years and have seen recent articles about the AMA having run millions into the "red," reducing staff and implementing other cutbacks.

In light of the news on technology and Internet stocks recently, I truly think it may be a financial folly for the AMA to be involved in a medical Web site, like Medem, at this time, especially viewing its past two year's financial performance.

--Brian P. Davey, MD, PhD Boynton Beach, Fla.

Don't open data bank

Focus on rebuilding medical team, not on error-reporting policies

The recent debate on medical errors, which has focused on reporting policies and privacy issues for physicians, hospitals and medical personnel, has entirely missed a golden opportunity to rebuild our medical team.

In recent years there has been a systematic dismantling of the delivery of medical care. Tremendous decreases in payments to hospitals and physicians has resulted in the closure of numerous quality hospital systems, early retirement of many important mentors, decreases in funding for research and training, and the destruction of the team responsible for delivering care to our patients.

I practice orthopedic surgery in a community setting. In my hospital, the nursing care has gone from one nurse for every three patients to one nurse for 15 patients with a couple of aides to help. One person cannot possibly deliver the same kind of care to that many patients. Relationships with physicians suffer, communication suffers and, ultimately, patients suffer.

Physician relationships have equally suffered. We are frustrated with cramming more people into our offices just to maintain or reduce the decline in our income; overburdened with paperwork; overwhelmed with justifying our recommendations to nonskilled people; and swamped with business decisions for our practices, with little or no training in that area.

As a result, we have forgotten how to behave to each other. Rarely do we communicate well among ourselves. There hardly is enough time to call our colleagues and discuss the consultation that was requested on a mutual patient. The writing in the chart is so rushed that it is usually illegible. There are multiple turf battles to carve out new niches in health care. In the midst of all this destruction of our field, the government decides to shift the focus of delivery of health care to reporting errors.

It is even more distressing that we actually took the bait. This is an ideal time to rebuild our team. We were much more effective 10 years ago when we all worked together. We must recognize the importance of each member of the team.

This is an ideal time for us to show that we cannot continue to give our patients the best care in the world if trends continue. We should be telling our society that one nurse cannot care for 15 people, that insurance administrators cannot make treatment decisions and that discouraging research and training will only lead to less quality in the future.

The AMA and our physician leaders should be detailing the destruction occurring and acting to rebuild the team, not focusing on reporting policies for errors. This red flag waved by our government is merely a ruse to keep us off the track. The big picture is determining how all of us can be more effective at what we do best -- caring for our patients. We should be educating society about the destruction and rallying them to our side. We need help to become effective caregivers again, and should be devoting our efforts to this cause.

--Robert Friedman, MD Pittstown, N.J.

No to universal health insurance coverage, yes to a free market

Paper or electronic, all medical records require protection