To The Editor:
The article "Of Geese and Golden Eggs" (81-A: 303-305, March
1999), by McCollough, is an eloquent and thoughtful discourse pertinent to
medicine in this era. Of particular interest is the comment, inter
alia, that society will view medicine as a trade rather than
a profession. There, coincidentally, is legislation pending in the
U.S. Congress that would grant physicians the legal right to collectively bargain.
What circumstances precipitated such a drastic measure?
As business considerations and economic survival increasingly
impinge upon the practice of medicine, it is crucial to consider
the professional ethic of medicine rather than allow this underlying
fundamental to become moribund. McCollough states that the true
source of economic well-being is the professional ethic of medicine.
It is unfortunate that this ethic is being eroded by the proliferation
of managed-care organizations (MCOs) with different and less altruistic
objectives. MCOs increase costs for physicians and reduce the ability
to focus on the professional ethic of medicine. It is necessary
to hire more and more staff to deal with MCO paperwork. Multimillion-dollar
salaries for MCO executives are commonplace2.
The authorization process for managed-care patients does not always
allow the professional ethic to be the primary consideration. If
there is no authorization, some MCOs require the physician to pay
for a service rendered by a secondary provider, such as a therapist.
Others charge "management fees" to physicians under the guise of
"administering" insurance claims; in other words, the physician
pays for the MCO to catalogue and "reprice" a claim and then redistribute
it to another insurance company for eventual payment.
In addition to increased overhead directly caused by burdensome
MCO rules and regulations, the ultimate affront is the unilateral
imposition of payment rates by MCOs. There is little or no contract
negotiation in the traditional sense. Rather, physicians are notified
of reduced compensation or simply are remunerated less for services
rendered at some MCO-designated time.
Has the time come for collective bargaining by physicians? Is
the future of orthopaedic surgery threatened to the point that physician unions
are conceivable? Does collective bargaining diminish the professional
ethic of medicine? These are questions that must be answered by
all of us and by the next generation of orthopaedic surgeons.
Jeffrey C. Dick, M.D.
Carlos A. Guanche, M.D.
John A. Steubs, M.D.
Kristin J. Brazier, C.C.S.-P.
Sandra J. Hokanson, C.C.S.-P.
Terri J. Wurscher, B.A.
Corresponding author: Jeffrey C. Dick, M.D.
Orthopaedic Consultants, P.A.
6465 Wayzata Boulevard, Suite 900
St. Louis Park, Minnesota 55426-1734
N. C. McCollough, III, replies:
The thoughtful letter from Dr. Dick and colleagues highlights
the dilemma confronting all physicians as they attempt to resolve
the conflict between professionalism and commercialism in medicine.
Against a background of progressive intrusion by managed care into
the economics of health-care delivery and the recent action by the American
Medical Association to support the organization of physicians for
the purpose of collective bargaining, Dick et al. pose the seminal
questions that all physicians must answer: "Is it time for unionization
of physicians?" and "Does collective bargaining diminish the professional
ethic of medicine?"
"Of Geese and Golden Eggs," an address to the new fellows of
the American Academy of Orthopaedic Surgeons, was written to provoke their
thinking about the value and importance of our professional heritage
and the consequences of neglecting to preserve it. Admittedly, the
hard questions posed by Dick et al. were not answered in this treatise.
Managed care, regardless of any efficiencies gained, has created
two fundamental problems for the physician: loss of income and loss of
autonomy in medical decision-making, which frequently has been harmful
to patients. In my view, if the primary purpose of collective bargaining
by physicians is to promote the welfare of our patients and it is
perceived by the public in that fashion, we will retain our professional standing
and we will be on sound ethical ground. But if collective bargaining
by physicians is undertaken primarily for economic self-interest and
the public perceives our goals to be self-serving, we will be on
the slippery slope toward loss of our professional standing and
we will have compromised the cardinal ethical principle of putting
the patient's interest above our own. It is unfortunate, but true,
that one of the reasons for the emergence of managed care was the
perception by many that physicians' economic self-interest was a
major cause of rising health-care costs.
Cruess1 stated that our profession
may have a rare opportunity to recover the public trust because there
is now a confluence between what the profession wants and what the
public wishes. If collective bargaining can be the means by which physicians
successfully advocate for their own autonomy and for their patients'
welfare, perhaps the age-old tensions between altruism and self-interest
in medicine can be moderated and a true partnership can be developed
between doctors and those entrusted to their care.
Newton C. McCollough, III, M.D.
Shriners Hospitals for Children
P.O. Box 31356
Tampa, Florida 33631-3356Occupational Orthopaedics