Letters to the Editor - April 11, 2005

Pay for increasing knowledge and you'll get better performance - Primary care residents should train more outside the hospital setting - If doctors are rated, then patients must promise to follow instructions - State medical boards should make decision on nonphysician prescribing

Pay for increasing knowledge and you'll get better performance

Regarding "AMA: Medicare pay-for-performance must be voluntary and not punitive" (Article, March 21): I respect and appreciate the efforts of the AMA to set forth worthy principles and standards in their Guidelines for Pay-for-Performance Programs. But I think the frog has leaped before it came into view.

Performance reflects knowledge, and the only way to derive data on performance is through education and its application to patient care. Education should be the first measure for payment enhancement, and implementation of practical learning into clinical practice should have measurable outcome opportunities.

There is a thirst for continuing educational and professional development, but the priority is often income-producing patient care. Creating a method in which educational effort can be rewarded will provide balance and has the best opportunity to improve care and outcomes. It will give specialty organizations the chance to become involved through the development of CME programs that are endorsed by payers and their pay-for-performance programs.

Demonstration of competency in various specialty-specific educational programs should be the first measure of enhanced value and will create the chance to evaluate the effectiveness of clinical advances to improve care and better use health care funds.

--Russell C. Libby, MD, Fairfax, Va.

Primary care residents should train more outside the hospital setting

Regarding "Illinois lawsuit could further restrict resident work hours" (Article, March 21): On the 80-hour workweek for residents, I feel that the biggest problem in internal medicine residencies is that the training for primary care and urgent care is extremely poor.

When I graduated residency, I was well trained as a hospital physician. This is because the academic medical centers need residents to take call. But most internal medicine residents are poorly trained for the primary care world that may lay ahead.

My solution would be for the third year of residency to be broken down between residents planning on specialties and those doing primary care. Those entering specialties would train in the traditional hospital manner. Those interested in primary care would spend at least five half-days a week in their own clinic or in an urgent-care setting. Internal medicine has failed its graduates in preparing them for a primary care career.

--Shailesh Bhat, MD, Woodland Hills, Calif.

If doctors are rated, then patients must promise to follow instructions

Regarding "Tiered physician network pits organized medicine vs. United" (Article, March 7): It will be an uphill battle to fight insurers who rate doctors on the basis of quality as a subterfuge for economic profiling if we don't think outside the box. Under this system, should doctors ask patients to sign a formal contract to follow instructions for follow-up, consultations, testing, etc., or face dismissal from our practice?

Perhaps the day will come when patients' "credentials" are rated and reviewed before a doctor will accept them. It's sad to say, but the sickest patients, along with the most noncompliant ones, might find it hard to get care in a system set up to save the insurer and the patient a buck. Now is a good time for doctors to consider this option to send a message to insurers and patients alike rather than wait to be abused further by the system.

--Rosario Romano, MD, Port Jefferson Station, N.Y.

State medical boards should make decision on nonphysician prescribing

Regarding "NP: Physicians don't have a monopoly on concern over patient safety"(Letters, Feb. 28): Currently, Kentucky has a bill before the state Legislature that would let nurse practitioners prescribe narcotics -- this in a state well known for its MS Contin abuse and meth labs and with marijuana surpassing tobacco as the No. 1 cash crop.

The argument of letter author David Kleberger, NP, of Commerce City, Colo., that he cares about patients as much as any physician may be true, and I have no reason to suspect he would abuse any prescribing ability he might gain in the future. But legislating the "handing out the keys to the candy store" or making it easier for patients to acquire and/or divert prescription drugs by giving extender providers the ability to prescribe narcotics (or any other drug) is not how society should keep a grip on potentially dangerous substances.

This should be a medical decision, not a government, legal decision. If it is deemed necessary to allow extender providers full prescribing rights, then the next logical question is, why not pharmacists, psychologists, social workers, RNs, EMTs, etc.? Certainly PAs should be included if NPs are given these rights.

Continuing along this line of reasoning, members of the lay public could then demand full access to any FDA-approved medication. Why not have all meds OTC? The consumer can go online, read up on what they want or what they think will help them, walk down to Wal-Mart, Rite-Aid or CVS and just buy what they want. They could save money by not having a co-pay, or the government would save on Medicaid office visits.

This is a matter of training, trust, experience and ability. Not all physicians should be allowed to prescribe certain medications. NPs and PAs are no different.

Some, like Mr. Kleberger, I'm sure, have the experience and competence to be able to appropriately prescribe some classes of medications. But who decides and how it is accomplished are not things that should be legislated -- they are things that should be decided by good medical practice and oversight by the state medical board and licensing agencies. There has always been a mechanism in any state whereby extender providers can write for controlled substances -- it's called medical school.

--William M. Bone, MD, PhD, Madisonville, Ky.