Correspondence
Professional Courtesy
N Engl J Med 1994; 330:1085-1086April 14, 1994
- Article
To the Editor:
In their article “Professional Courtesy -- Current Practices and Attitudes” (Nov. 25 issue),1 Levy et al. do not mention an important point. To be asked to treat one's colleague or his or her family is the greatest honor bestowed on a physician. It clearly bespeaks the deepest trust and respect for the physician's skills and practice of medicine. I personally would gladly treat any physician or that physician's family members, no matter what the reimbursement.
1 ReferencesJesse V. Wassner, M.D.
128 Union Ave., Rutherford, NJ 070701
Levy MA ,Arnold RM ,Fine MJ ,Kapoor WN . Professional courtesy -- current practices and attitudes. N Engl J Med 1993;329:1627-1631
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To the Editor:
Most of the objections to professional courtesy pointed out by Levy et al. and Steinbrook1 have not been proved. I suspect they arise mainly from some people's concern over possible elitism and the implications of specialness.
I have always believed that professional courtesy originated with the Hippocratic oath and was a means of repaying a debt to teachers and colleagues for having taught us and for other acts of collegiality and generosity. I only regretted that as a psychiatrist I could not extend this courtesy as freely as I would have wished. At any one time, a third to a half of my patients were potential recipients of professional courtesy, so I could not afford it. There were also theoretical objections to offering psychotherapy free in certain situations.
I think it is impossible for anyone to love equally the several billion people who occupy this earth, who are necessarily an abstraction. When I became a physician, my family, my kin, my friends, and my neighbors were already special. As the list has expanded to include colleagues in medicine and then people in allied professions, such as nurses and clergy -- well, the list continues to grow. I do not think that other patients have suffered from this.
Rather than motivated by a desire to give and receive preferential treatment at the expense of other patients, professional courtesy is fueled by gratitude. A feeling that we owe, rather than are entitled to, is not a bad one with which to start one's practice of medicine.
1 ReferencesEdith T. Shapiro, M.D.
University of Medicine and Dentistry of New Jersey, Newark, NJ 071031
Steinbrook R . Rethinking professional courtesy. N Engl J Med 1993;329:1652-1653
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To the Editor:
Virtually all professions extend courtesy to members of their ranks. Airline employees receive free flights, department-store workers receive discounts, attorneys provide free civil work for one another, and members of the theater community give fellow artists “comp” tickets to shows. It is absurd to suggest that the practice is or should be any different for physicians. . . .
The notion that professional courtesy insulates the physician from the rising costs of medicine is also absurd. Physician-to-physician professional courtesy does not extend to drugs, laboratory work, medical supplies, hospital charges, or insurance costs. These additional costs account for approximately 80 percent of the total costs of health care. Only 20 percent of such costs are covered by professional courtesy.
Barry A. Kohn, M.D.
Allergy and Pulmonary Consultants, Fair Oaks, CA 95628To the Editor:
. . . Physicians have also given professional courtesy -- that is, accepted insurance payment only -- to nuns, priests, ministers, rabbis, indigent patients, nonindigent patients without insurance, and many others. If we are going to rethink professional courtesy and consider that it may not be appropriate on a physician-to-physician basis, we must also consider the other people who receive such courtesy. To this list, one might add nurses, hospital administrators, and members of boards of trustees.
I believe physicians should leave alone this time-honored method of saying thanks to those who assist in patient care and of lending a hand to those who cannot afford care.
Herbert S. Bell, M.D.
34900 Chardon Rd., Suite 107, Willoughby Hills, OH 44094To the Editor:
As a medical student and resident, I always appreciated professional courtesy the few times I was ill. Later, when I became a staff member in a teaching hospital and made a good salary, the concept made less sense. For example, I asked our underpaid and overworked private pediatrician to bill me for his services, because it made me feel more comfortable. He kindly refused on several occasions, which made my wife and me feel uneasy about scheduling visits for our children.
Recently, most physicians either have not extended professional courtesy or have honored my request to reimburse them for uninsured services. Two years ago I received a long-overdue physical examination from a colleague. At the end of the visit, he adamantly refused to honor my request for normal billing. I persisted, and he said he would “think about it.” I never received a bill and honestly will be reluctant to seek his help in the future.
In my opinion, if a physician asks a colleague to make a normal charge for services rendered, this request should always be honored.
Jack E. Meyer, M.D.
Brigham and Women's Hospital, Boston, MA 02115Author/Editor Response
The authors reply:
To the Editor: These responses, as well as others we received directly, support our findings: The vast majority of physicians offer professional courtesy and, for a number of specific reasons, feel positive about the practice.
Bell points out that physicians do provide free or discounted care to patients other than physicians. Although we did not include these data in our paper, we found that many physicians often or always provided free or discounted care to nurses (53 percent of physicians), dentists (33 percent), clergy (38 percent), “indigent patients” (65 percent), medical students (71 percent), residents (69 percent), and hospital employees (37 percent). Conversely, few physicians offered discounts to lawyers (3 percent) or “prominent citizens” (6 percent). We agree that physicians may want to reconsider their rationale for providing discounted care to such groups, in particular to those most able to afford medical care.
Shapiro and Bell state that professional courtesy is a means of expressing gratitude to other physicians. There are several reasons that offering free medical care may not be the most appropriate manner of expressing such gratitude. If one is providing professional courtesy for this reason, it would be ethically less problematic to offer free care than to use the potentially fraudulent practice of billing the amount covered by insurance only.1 In addition, as Steinbrook points out in his editorial, the mere appearance of favoritism and elitism should be a source of real concern for the medical profession.
In response to Kohn, we cannot comment on how frequently members of other professions receive professional courtesy or perquisites such as free travel. Although medicine is clearly a business, comparing medical care provided as a courtesy with free airline tickets trivializes the complex issues involved in patient care.
Shapiro correctly points out that the objections raised in our discussion have not been proved. Indeed, these theoretical objections may not be empirically provable. We believe, however, that any practice that may adversely affect the physician-patient relationship should be avoided. The comments from Shapiro and Meyer support the idea that professional courtesy may interfere with the physician-patient relationship. We agree with Meyer that doctors should not force professional courtesy on people who may feel more comfortable paying for their medical care.
1 ReferencesMark A. Levy, M.D., M.P.H.
Medical Center of Central Massachusetts, Worcester, MA 01605Robert M. Arnold, M.D.
Wishwa N. Kapoor, M.D., M.P.H.
Michael J. Fine, M.D.
University of Pittsburgh, Pittsburgh, PA 152611
Lachs MS ,Sindelar JL ,Horwitz RI . The forgiveness of coinsurance: charity or cheating? N Engl J Med 1990;322:1599-1602
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Author/Editor Response
Dr. Steinbrook replies:
The letters, as well as the response from Levy et al., illustrate the diversity of views about professional courtesy. In my editorial, I aimed to encourage a fresh evaluation of this practice at a time of widespread change in the American health care system. Two specific points should be highlighted. As Wassner points out, the honor and trust inherent in treating a colleague or his or her family should not be confused with the financial arrangements. In response to Kohn, I am not convinced that professional courtesy in medicine should be justified on the grounds that other professions follow similar practices. Physicians must often hold themselves to particularly high standards, which sometimes may mean avoiding practices that are common elsewhere.
Robert Steinbrook, M.D.
