Correspondence

Should Legislatures Practice Medicine?

N Engl J Med 1997; 337:1240-1241October 23, 1997

Article

To the Editor:

Generally, I heartily agree with you (June 12 issue)1 that legislators should not be practicing medicine. However, the issue of partial-birth abortion should not be mixed in with the others. The concern over this matter, as opposed to a need for mammography or hospitalization for delivery, is one of morality and is properly a decision more for our elected representatives than for doctors. The question of whether the fetus at any certain age is a human being worthy of society's protection against violation cannot be decided by scientific evidence. This question, however, is appropriately addressed by the House of Delegates of the American Medical Association, which is a deliberative body that can properly speak to policy on moral as well as scientific issues.

Anthony M. Perry, M.D.
327 N. Washington Ave., Scranton, PA 18504

1 References

1. 1

   Kassirer JP. Practicing medicine without a license -- the new intrusions by Congress. N Engl J Med 1997;336:1747-1747
   Full Text | Web of Science | Medline

To the Editor:

. . . Whether health plans can deny coverage for hospitalization beyond 24 hours for a normal delivery is a health policy and not a medical decision. There has been no congressional mandate that physicians keep women hospitalized for 48 hours; such a requirement would indeed represent the practice of medicine without a license. Attempts to provide insurance coverage for care that may well improve health outcomes should receive the support of physicians. Whether, indeed, certain practices are beneficial should be critically assessed while their coverage is protected.

Andrew C. Gorchs, M.D.
Medical College of Virginia, Richmond, VA 23298-0509

To the Editor:

I agree with you that Congress should “stay out of the examining rooms.” However, the driving force behind the flood of legislation in California is not a desire on the part of politicians to practice medicine, but a desire to rein in what is perceived by lawmakers and their constituents to be the venality of health-maintenance-organization (HMO) administrators in a rapacious scramble for market share. In the California assembly nearly 50 bills related to HMOs have already passed, and 30 or more have moved through the senate. Among other things, these measures mandate coverage for mental health care and contraceptive devices, allow HMO members direct access to specialists, require health plans to pay for second opinions, and even require the HMO to answer the telephone promptly and schedule appointments within 10 working days.

I agree that politicians respond to the emotional appeals of their constituents. But I think it important to keep in mind that, at least in California, that response is intended to strengthen the rights of physicians and patients when dealing with the large corporate entities that seek to control the practice of medicine to a degree that far exceeds that of either the state or the federal government.

Joan Venes, M.D.
University of Michigan, Ann Arbor, MI 48109

To the Editor:

I take issue with your editorial chastising Congress for legislation concerning certain medical procedures. On the contrary, practicing physicians and their patients are desperately in need of Congress's protection against our common enemy, the insurance carriers. Most of the legislation to which you refer does not step between doctor and patient. It merely protects the public against interference with the doctor–patient relationship by insurance companies that are only concerned with their unconscionable profits. More legislation is needed. For example: (1) a law that requires that a medical professional (e.g., physician, nurse practitioner or physician's assistant) with 10 years of practice experience be at the telephone approval desk of managed-care companies, and (2) a law that waiting on hold for more than one minute when telephoning for approval of a procedure or hospital admission mandates automatic approval of the request.

You are not in private practice. If you were, you would be grateful to the Congress for its protection.

John H. Robert, M.D.
9235 158th Pl. N.E., Redmond, WA 98052

To the Editor:

Your excellent editorial raises the big question: How do physicians become involved in the political process and help regain control over medicine?

Here in California, politicians continually attempt to micromanage medical care. Although they rarely have a background in science or medicine, they craft emotionally based legislation that tells us how we should practice medicine.

For example, a recent bill, which was narrowly defeated, would have required physicians to offer a blood test for prostate-specific antigen during every office visit. Fortunately, with the intervention of the state medical association, the bill was amended to require a prostate-specific–antigen test after an abnormal digital rectal examination — already the standard of medical care.

Physicians need to become more involved in politics, and they must collectively support other physicians interested in participating in the political process. This could be done in an organized fashion, such as through the creation of an EMILY's List of physicians, or in any manner that assists physicians in gaining office.

Jonathan D. Pritikin, M.D.
2200 O'Farrell St., San Francisco, CA 94115

To the Editor:

In your editorial you state that “regulation by the FDA [Food and Drug Administration] is based on carefully evaluated scientific judgments by experts and is shielded from direct intrusion by legislators. Similarly, NCI [National Cancer Institute] advisory panels base their decisions on hard scientific evidence.” You certainly must know that the regulatory process, whether at the NCI, FDA, Environmental Protection Agency, or Department of Agriculture, has been heavily compromised by intensive corporate lobbying. . . .

Lynn H. Ehrle, M.Ed.
8888 Mayflower Dr., Plymouth, MI 48170

Author/Editor Response

Dr. Kassirer replies:

To illustrate intrusions by Congress into medical practice, I cited three examples: the promotion of mammography for women in their 40s, the attempt to outlaw certain abortion procedures, and the requirement that health plans cover hospital stays of up to 48 hours for new mothers. I never expected (and did not get, as the letters from Drs. Gorchs and Perry attest) universal agreement on these specific instances, but only consensus that some of these are exemplars of a growing and serious problem.

The letters from Drs. Robert, Venes, and Pritikin vividly illustrate my point that a distinction must be made between appropriate laws that protect the public against the abuses of insurance carriers and unacceptable legislation that interferes with the proper practice of medicine or the physician–patient relationship. Like Drs. Venes and Robert, I, too, want to protect the public, yet I believe that both of the laws on prostate-specific–antigen testing described by Dr. Pritikin represent inappropriate meddling in medical practices.1

Ehrle is right, of course, that governmental agencies are often heavily influenced by lobbyists, but I made a distinction between strong influence and direct intrusion in medical practices by legislators.

I do not agree with Dr. Perry that the abortion issue is different, and I am less sanguine than he that the House of Delegates of the American Medical Association is the right forum for such decisions. I believe that such personal decisions are best handled by a woman, her family, and her physician.

Jerome P. Kassirer, M.D.

1 References

1. 1

   Pauker SG, Kassirer JP. Contentious screening decisions: does the choice matter? N Engl J Med 1997;336:1243-1244
   Full Text | Web of Science | Medline