American College of Physicians: Internal Medicine — Doctors for Adults ®



From the July/August 1998 ACP-ASIM Observer, copyright 1998 by the American College of Physicians-American Society of Internal Medicine.

More on NPs

The commentary by Geraldine Wade, ACP-ASIM Member, lamenting the encroachment of nurse practitioners (NPs) into primary care underscores the importance of developing valid quality measures. ("Hippocrates beware: NPs eroding practice of medicine," April ACP Observer, p. 4.) Gauging practice for NPs should not be based on personal anecdotes and economic turf battles but instead on objective data.

NPs need to prove their worthiness on the primary care "playing field." If NPs can perform just as well as physicians in straightforward process measures and sophisticated outcome measures, and if they can earn equivalent patient satisfaction ratings, what is wrong with them practicing primary care? If NPs prove they can provide low-cost, high-quality primary care, they will have carved a competitive niche in an increasingly market-driven practice environment. We physicians would be better served by focusing more attention on improving our own primary care performance, which, as numerous studies have shown, leaves much to be desired.

John Y. Oh, ACP-ASIM Member
Owings Mills, Md.

I read with great satisfaction the letter by Dr. Wade. She eloquently verbalized my feelings about the use of "midlevel health providers."

Like many physicians, I have been going through some difficult times to become board-certified in three specialties—internal medicine, endocrinology and gastroenterology—and I am a little disturbed by a lack of respect in the health care community. It seems that the opinions of NPs and physician assistants carry similar weight as those of doctors.

I am happy that somebody finally spoke up, and I wish the College would embrace Dr. Wade's comments

Tom Dunzendorfer, ACP-ASIM Member
Monroe, N.Y.

Separate contracting

I disagree with ACP-ASIM's position regarding separate contracting for Medicare. ("New ACP-ASIM paper: private contracting threatens Medicare," May ACP Observer, p.3.) I am seriously considering separate contracting, not because of reimbursement issues but because of the steady criminalization of Medicare billing. Physicians are presumed guilty until they prove themselves innocent.

While I will not abandon my Medicare patients, I cannot put myself in legal jeopardy for the privilege of caring for those who need my care most. I will probably earn less than I do now, since many patients will not be able to pay more than the current Medicare copayments. But I won't have to worry that an innocent code transcription error by my office manager or misinterpretation of medical information by a nonmedical bean counter will lead to bankruptcy or prison.

Private practice remains a small business. Accepting the financial and legal ramifications of Medicare is bad business. Those of us who still treat Medicare patients do so because our mission is to tend to the sick. Separate contracting will preserve medical care for the elderly. The current trend will destroy it, as physicians who find they have no choice in treating or billing will leave the system.

Susan K. Sorensen, ACP-ASIM Member
Palo Alto, Calif.

Patient advocate

The president's column by Harold S. Sox, FACP, about being "caught in a box with technology" bothered me. ("The dilemma of internists: caught in a box with technology," May ACP Observer, p. 11.) I have long taken the position that the physician should be the patient's advocate. Dr. Sox's mention of the Annual Session presentation by David Eddy, MD, suggests that he agrees that physicians must "accept responsibility for allocation policies that take account of the finite resources that are available for their health care."

I believe the physician must be an unequivocal advocate for the patient, not for society. Society will set up its own safeguards and establish its own limits on expenditures for care. However, when a hospital or an HMO sets limits on care, who besides physicians will speak up for patients and act as their advisors?

In addition, how do we determine who will benefit most from anything? Very few—if any—clinical decisions have simple answers. Certainly, we have to estimate and consider both the risks and the benefits to the patient. If the institution cannot provide what the physician thinks is worth trying and the patient wants, then the physician should help the patient find an institution where that care can be provided.

Patients need to be aware of the "system" of care being used to provide care and the contracts that physicians have signed. They should also be aware of any limitations under which the physician/patient relationship is established. Ideally, physicians should provide this information when beginning a relationship with patients, often when they still are well.

Lawrence R. Freedman, FACP
Los Angeles


I have practiced internal medicine for 30 years in Ossining, N.Y. Working in today's turbulent world of medicine, I had to ask myself, "What are my beliefs?" Here are my responses.

  • I believe that medicine is both an art and a science.
  • I believe that patients are complex human beings who need time to be understood.
  • I believe that I should have enough time to explain to my patients what is wrong with them and the reasons behind the tests I order.
  • I believe that I should practice medicine conscientiously and carefully.
  • I believe that a big part of healing is in the relationship between the physician and the patient.
  • I believe that the load on internists, i.e. patient load, reports and paperwork, is pushing them to the point where they can no longer do their jobs to the best of their ability.
  • I believe that most insurers vastly underpay internists for the time and effort required to practice medicine with care and compassion.
  • I believe that the health care system is in a major crisis, and that the insurer and the internist are on a collision course.

Harvey I. Hurwitz, ACP-ASIM Member
Ossining, N.Y.

Fair cost for care

It seems to me that no one is addressing an important issue regarding health care costs. The usual perception persists that health care and insurance costs have risen because everything in health care has become more expensive. Nothing could be further from the truth. In areas with high managed-care penetration, for example, the reimbursement for each service is declining-often dramatically.

In addition, patients have access to many more services. The number of available tests and procedures has exploded. MRIs, laparoscopic surgery, endoscopic procedures, cardiac catheterization and even transplants are being performed routinely, and they all cost money. New medications with greater efficacies and improved side-effect profiles also cost more money. And insurance has become more expensive as plans pick up the cost of medications that were not covered in the past. Someone has to bear the cost, whether it be an individual or an insurance pool.

I wonder how many people would accept a cheaper health care system or an insurance plan that limited technological and pharmaceutical advances to the 1978 standard. Things would be much cheaper if patients agreed to forego CT scans, PET scans, routine colonoscopies, etc. How many people would be willing to limit their formulary choices to what was available 20 years ago? Reserpine, propranolol and antacids are very inexpensive.

If you upgrade from a 1978 Pinto to a 1998 Cadillac, you can't expect to pay the same price-even after adjusting for inflation. But that is what the public expects!

Gustavo A. Calleja, ACP-ASIM Member
Coral Gables, Fla.

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