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


September Letters

Quality incentives

The concept of a reward system for a job well done should be promoted. ("As they struggle to improve quality, HMOs try a new incentive: bonuses," June ACP-ASIM Observer, page 1.) When such a reward system bases its decisions on flawed data, however, it only disenfranchises physicians.

Some of these systems choose not to collect useful data and instead rely on faulty claims information. As a result, they penalize physicians for failing to screen male patients for breast and cervical cancers. These types of glaring errors cause physicians to lose faith in quality grading systems, even when their compensation is on the line.

Even more ominously, some reward systems unfairly punish good physicians. Systems that base bonuses on per-member costs of care, for example, often penalize physicians who have a higher cost profile because they aggressively use statins, ACE inhibitors, beta-blockers and cardiac rehabilitation for patients with coronary artery disease and mild heart failure.

When health plans create tools to evaluate and reward physician performance, science and common sense should prevail.

Basil E. Akpunonu, FACP
Elizabeth A. Hoffman, MD
Toledo, Ohio

Ethics case study

The recent ethics case study examines whether health plans are hurting generalist-specialist relationships when a general internist takes over the care of a patient admitted to the hospital by a cardiologist. ("Are health plan incentives hurting generalist-specialist relationships?" June ACP-ASIM Observer, page 1.)

The real problem is that no one is asking the obvious questions: Why is a cardiologist admitting a patient with a myocardial infarction? Why isn't the general internist admitting the patient and consulting a cardiologist if needed?

As generalists become more uncomfortable caring for sick patients, specialists will increasingly take over cases that primary care doctors should be able to handle. This trend will lead to increased costs, overutilization of specialists, an increased need for more specialists and the continued atrophy of primary care physicians' clinical skills.

We should use our valued specialist resources wisely, which requires primary care doctors to do their jobs. If we primary care doctors can't or won't take care of sick patients and physician extenders are hired to replace us to do "well-patient care," we should not be surprised if we become obsolete.

Mark McConnell, ACP-ASIM Member
La Crosse, Wisc.


While I look forward to reading the final version of the new charter on physician professionalism, I have some concerns about how it will be interpreted. ("Charter on medical professionalism addresses issues of finite resources," July/August ACP-ASIM Observer, page 1.)

In my work as an educator, I often hear students, residents and even staff misuse the term "cost-effective." Rather than obtaining sufficient information to compare the effectiveness, benefits and costs of two therapeutic interventions, some use the term as a pseudo-authoritative way to express their personal judgment that a test or treatment is too expensive for a particular patient. Many even use the term "too expensive" with the goal in mind of saving money for the nation's health services.

I have several objections to this way of thinking. For one, we don't know how this "saved money" will be used. Rather than improve health services, the funds could just as easily be used to build more roads or subsidize tobacco farmers.

To my knowledge, the AMA's patient-physician covenant states that physicians should provide the best medical advice and care, taking into account the least expensive way of accomplishing the desired effect. If we were to use cost as the deciding factor in medical recommendations, how would we explain this to patients?

Finally, the current emphasis on medical costs implies that until now, physicians have not seriously taken cost into consideration. This supposition seems to be a "straw man" constructed to allow physicians to make societal decisions at the expense of the individual patients with whom they have a specific contract to provide the best medical care.

The current discussions of the costs of care regularly neglect any proposal to ameliorate the situation other than spending less on patient care. Certainly, there are other competing interests in society. But if physicians believe that the nation's health services need more financial support, why don't we ask for it?

It is time for physician organizations to devote themselves to advocating for measures that improve the health of society. Such advocacy should be free of any suspicion of economic self-interest and allow us to fulfill our responsibilities to both the medical profession and to society.

Lawrence R. Freedman, FACP
Los Angeles
Editor's note: Dr. Freedman is chief of medical and dental education at the Veteran Affairs Greater Los Angeles Health Service and professor of medicine at the University of California, Los Angeles.

In the article on professionalism and finite resources, we learn that doctors should observe "the primacy of patient welfare," should "meet the individual needs of their patients," "avoid unnecessary tests and procedures," and be concerned with the "fair distribution of health care resources." All of these recommendations are basic characteristics of the ethical doctor and the good citizen. They were commonly taught and accepted even as far back as 1944, when I graduated from medical school. I wonder if a cost-effectiveness study of the charter might not be appropriate.

Saul B. Gilson, FACP
New York

Health care's woes

As a medical teacher for 20 years, I can understand why Christopher Boni, ACP- ASIM Member, is dismayed and disappointed that his teachers did not alert him to the profession's disquietude. ("Responsibility for health care's woes," July/August ACP-ASIM Observer, page 3.)

I doubt that Dr. Boni's teachers were fully aware themselves of the vexations of private practice today. While those in academia are cognizant of managed care's economic stranglehold on health care, most do not experience the day-to-day financial and clerical aggravations endured by private practitioners and their staffs.

Training programs started to lose valuable input from community practitioners three decades ago when private physicians began to be replaced on rounds by physicians who work in the hospital full time. While community doctors may not have known about the latest research or diagnostic breakthroughs, they added prudence and practical wisdom to ward rounds that no white-frocked academician shares. I am sorry that Dr. Boni was cheated of this learning experience.

Lee R. Sataline, FACP
Cheshire, Conn.


It is clear from the volume of letters published in ACP-ASIM Observer and the prevailing feeling among my colleagues that the new proposed process of recertification is wrong. Recertification represents the work of a group of academic physicians who have no concept of the daily pressures of community practice. Practicing physicians should have a greater say in the design of the process because we are the ones who deliver care.

I ask the College to not repeat the AMA's mistake of losing touch with the grassroots members. ACP-ASIM must react with strength and decisiveness to this most onerous and ill-conceived process, which threatens our daily livelihood and further serves to divide us.

Arthur W. Hammer, FACP
Roslyn, N.Y.


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