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OPINION

Letters to the Editor - Aug. 13, 2007

Referral rule change not in sync with real world of medical practice - Physicians shouldn't casually dismiss patient mistrust of treatment plan

Referral rule change not in sync with real world of medical practice

Regarding "Rule changes for referral documentation create confusion" (AMNews, July 9): This is one more nail in the coffin of medical quality.

The U.S. is suffering in quality of care by several reviews. Are the rules noted going to improve quality?

In our community, I feel we have a very good set of specialists, with some areas covered by more than one specialist or group of specialists. My goal is to have the patient seen by the first available specialist who accepts Medicare (Thanks for your rules, CMS, but some are saying no to assignment now -- wonder why?). At the point of care, when I make my referrals and indicate the reason, I do not know who the referral staff will find to fulfill my need. If I have to do as indicated [by one expert quoted in the article], that is, specify the name of the specialist and not just say referral to cardiology, for example, the task of creating referrals becomes another process to track.

I think that it would be very good for real doctors in real practices, practicing evidence-based medicine, to begin to make real rules that we can function under. Practicing in the real world would help them to formulate standards they themselves, as full-time harried physicians, can understand, comply with, and work across the board for all insurers.

I, for one, am seeing administrative physicians as living in a fantasy world of ideals rather than practical steps, as not communicating with administrators of other insurers to coordinate requirements and to track how all of these rules are being managed by physicians.

--Paul Nault, MD, Prescott, Ariz.

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Physicians shouldn't casually dismiss patient mistrust of treatment plan

Regarding "Doctors and patients may not always agree" (See column, July 2): I read this article with keen interest and agreed with all the sensible advice from Sandeep Jauhar, MD, PhD. The problem however is far deeper, widespread and troublesome than an occasional honest disagreement between the patient and doctor as to what is necessary treatment.

There is a serious problem across the globe about trusting doctors, whether they have your best interest in their hearts or are primarily motivated by other considerations.

In India, patients routinely will not give but limited information lest the doctor gets wrong ideas about the scope of treatment. Hospitals are often euphemistically referred to as butcher houses to give vent to the deeply held conviction that surgeons often operate unnecessarily.

There is a widespread fear among U.S. teenagers that if one buckles and gives in to seeing a psychiatrist one will be immediately put on powerful psychotropic medications. Until just two decades ago psychiatric patients often stayed for years, and sometimes for life, in institutions because of routine abuse of involuntary commitment laws. ECTs, seclusions and restraints, once a staple of psychiatric hospitals, have become a rarity, thanks to the evolving consciousness that it pays to resist overzealous treatment.

And the problem is not just in the field of psychiatry.

A few years ago, in a renowned university hospital, a cousin of mine, also a doctor, had extreme difficulty in preventing doctors from doing brain surgery upon his mother's alleged pituitary tumor, which was actually an edematous swelling due to psychogenic polydipsia. As a rule, doctors are in severe denial over how financial motives and other vested interests influence their medical conduct.

When a patient disagrees with you, the first assumption should not be on how to convince the patient to change his mind about his bad decision. The physician must do some soul searching whether the patient is not more medically and economically correct on the matter than the doctor.

--Surendra Kelwala, MD, Livonia, Mich.

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Copyright 2007 American Medical Association. All rights reserved.