Correspondence

Truth or Consequences

N Engl J Med 1998; 339:410-412August 6, 1998

Article

To the Editor:

Dr. Levinsky (March 26 issue)1 recommends “telling patients the truth” as the best way for doctors to deal with the problem of rationing of medical care. As appealing as this advice is, it falls short of solving an important contemporary medical dilemma. For example, the patient with multiple sclerosis who is told that interferon may be of therapeutic value but that the health maintenance organization (HMO) will not pay for it under any circumstances will have to live with this information. It is too late to switch to another HMO. The truth then becomes a source of frustration and an unjust, additional burden for the patient. This dilemma is a byproduct of a health care system in which there are significant disparities among the vast array of plans and among different regions of the country. It becomes another powerful argument for a nationalized system in which there are uniform guidelines by which the rationing of medical care can be made acceptable.

Victor Gurewich, M.D.
Mount Auburn Hospital, Cambridge, MA 02138

1 References

1. 1

   Levinsky NG. Truth or consequences. N Engl J Med 1998;338:913-915
   Full Text | Web of Science | Medline

To the Editor:

Levinsky includes as examples of rationing not ordering an expensive test when its likely yield is low (albeit not zero) and selecting a slightly less effective but much less costly treatment over a slightly more effective but much costlier alternative. Conscientious physicians have always made choices of this sort, not with an eye toward personal gain or avoiding punishment but from a sense of what is prudent and reasonable as opposed to excessive and from a desire to be good stewards of health care resources. The notion that there is a limit to what it is acceptable to spend to obtain a certain level of health care is inherent in calculations of an intervention's “cost per year of life saved,” an accepted part of the cost-effectiveness analysis that Levinsky advocates. Physicians have their own intuitive sense of reasonable limits (however arbitrary and inconsistent they may be), are reluctant to exceed them, and endeavor to transmit this value to their trainees, independently of any interference from administrators or others. The implication that good health care entails the provision of every intervention that offers any degree of benefit, irrespective of cost, unless there is an equivalent but less costly alternative, or unless the patient is fully informed of the decision not to provide the intervention, conflicts with my sense of our profession's internal ethic.

Substitution of the term “necessary medical care” for “effective care” (as occurs midway through the article), although perhaps good rhetoric, distorts reality. I doubt that many caring physicians would voluntarily withhold care they perceive as truly necessary, whereas many in good conscience (and without having their arms twisted) would withhold care that is marginally effective but extremely expensive.

James R. Johnson, M.D.
Veterans Affairs Medical Center, Minneapolis, MN 55417

To the Editor:

Many primary care physicians are salaried employees of group- or staff-model practices. As salaried employees, we need to maintain a certain level of productivity in order to support our salaries. Our productivity contributes not only to incentive pay but also to our base salary. When we stop patients from telling us about the last issue they want to discuss that day, or when we avoid probing too deeply into an issue because of time constraints, we do not openly acknowledge what is driving the process.

At times, our haste is driven by a waiting room full of patients. They may be waiting because of a policy that requires a patient to be booked every 15 or 20 minutes in order to support a six-figure salary. Some days, we cover all issues with our patients, including time-consuming education. As a result, our day may end quite late, causing some patients to wait more than an hour before being seen. Other days, we keep the discussion short, so that we can stay on time.

To support our salaries, we need to see a certain number of patients per year. To fit these patients into our schedules, we need to have them slotted at a particular frequency. Yet we do not tell our patients the ultimate reason we are unable to spend sufficient time with them to discuss all their issues. Shouldn't we be disclosing this information? Shouldn't we as physicians acknowledge that we tacitly support abbreviated discussions with our patients in order to maintain a certain level of “productivity,” and thus, a certain salary level? When we finally acknowledge the impact of our behavior on our salaries, then and only then will we be able to take an ethical stand.

Jerry Sobieraj, M.D.
Boston University Medical Center, Boston, MA 02118

To the Editor:

Although it is certainly true that physicians' financial and contractual relationships with HMOs threaten truth telling, I wonder whether physicians have ever lived up to Levinsky's lofty standard.

Under the fee-for-service system, millions of operations, such as hysterectomies and tonsillectomies, were performed, with great financial benefit to the doctors but no medical benefit to the patients, who were exposed to risk.1 Physicians routinely order tests not because they are medically indicated but because the physicians worry that failure to do so will open them to malpractice litigation.2 In the early 1990s, the profession was tarnished by scandals involving physicians who referred patients to laboratories and imaging centers in which the doctors held a secret financial stake.3 Rarely, in any of these instances, did the physicians level with their patients about all the nonclinical factors influencing their decisions.

Now we are witnessing efforts to “align the incentives” of doctors with those of the giant, profit-driven corporations to which they are increasingly beholden. But are such efforts corrupting physicians or simply taking advantage of the willingness of far too many of them to be corrupted?

Timothy B. McCall, M.D.
176 Pearl St., Cambridge, MA 02139

3 References

1. 1

   McCall TB. Examining your doctor: a patient's guide to avoiding harmful medical care. Secaucus, N.J.: Carol Publishing Group, 1995.
   

2. 2

   Lawthers AG, Localio AR, Laird NM, Lipsitz S, Hebert L, Brennan TA. Physicians' perceptions of the risk of being sued. J Health Polit Policy Law 1992;17:463-482
   CrossRef | Web of Science | Medline

3. 3

   Mitchell JM, Scott E. New evidence of the prevalence and scope of physician joint ventures. JAMA 1992;268:80-84
   CrossRef | Web of Science | Medline

Author/Editor Response

Dr. Levinsky replies:

To the Editor: Dr. Gurewich calls attention to the psychic burden and frustration of patients who discover that they are not insured for the cost of necessary therapy. Both private and national health insurance programs should be required to give people clear information about coverage and exclusions when they enroll, provide for input from the public and the medical profession in setting and updating the limits of coverage, and offer an effective mechanism for appeal in individual cases. Such procedures will reduce, although they cannot eliminate entirely, the problem Dr. Gurewich discusses.

I agree with Dr. Johnson that many physicians subconsciously (intuitively) restrict the use of very expensive, marginally effective therapy. I do not advocate the use of cost-effectiveness analyses by practitioners for such day-to-day decisions. Rather, I suggest in my article that doctors test their decisions by asking whether they would make the same choices for themselves and their families.

Drs. Sobieraj and McCall point out that economic self-interest or even greed may influence the way some physicians practice medicine. I agree. Nevertheless, I believe that most physicians strive to conform to ethical ideals. Telling patients the truth about rationing decisions is an important part of those ideals.

Norman G. Levinsky, M.D.
Boston University Medical Center, Boston, MA 02118