March 1927, 1952, and 1977
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"Ive never got over my indignation at finding out that some surgeons do operations primarily for the money," wrote internist B.Z. Paulshock of Wilmington, DE. "Pecuniectomies are immoral as well as unethical, and if the medical profession cant police itself against them, then [health insurers] have an obligation as well as a right to do so."
Was hers just another voice raised against unnecessary surgery, another protest triggered by studies purporting to show that fee-hungry American surgeons were too quick to start cutting? No, Paulshocks concern went beyond that. She worried that the anti-pecuniectomy backlash would prevent patients who needed surgery from getting it.
Insurers around the nation were launching second-opinion programsmany of them mandatoryin an effort to reduce the volume of elective operations. Several of the programs required that the second opinion had to come from a doctor who was on the insurers panel of consultants. Early studies indicated the effort was paying off: A high percentage of patients whod gotten second opinions stayed away from the OR.
That troubled Paulshock. "Second-opinion studies shouldnt be turned into a numbers game," she cautioned. "Seeking a second opinion in any case where the physician or the patient is in any doubt about diagnosis or treatment is good medical practice. But the purpose should always be to protect the patientnot to protect the carriers pocketbook."
One consequence, she feared, was that a number of common procedures might be labeled "unnecessary" by the insurers consultants, leading to coverage denials. "A return to the concept of surgerys being indicated only for situations in which there is threat to life is simply not acceptable," the internist argued. "The discomforts and inconveniences of hemorrhoids, unstable knees, excessive vaginal bleeding, and so on are in many instances worth surgical amelioration. Its patients like these wholl suffer if the carriers begin denying reimbursement for nonessential surgery."
Paulshock called on her nonsurgical colleagues to help in the fight against that. "We can speak out to let the general public know what it may be denied," she wrote. "We can offer our maximum cooperation in carefully designed, unbiased research to help evaluate the true frequency of genuinely unjustifiable surgery.
"We can insist that second-opinion programs be voluntary. To do otherwise is to say that all surgeons are crooks. And there should be free choice of specialists as consultants. In many instances, the doctor best qualified to give a second opinion about the desirability of elective surgery may be an internist or family physician, rather than a surgeon."
Twenty-five years earlier, one communitys doctorssurgeons and nonsurgeons alikehad their own "image" problem to deal with.
An article that first appeared in the Santa Clara, CA, newspaper and then circulated nationwide provoked as much anger as it did heartbreak: A 6-year-old was doomed to death from nephritis because no doctor would treat the youngster at no charge or give his destitute parents free medicine. Thousands of dollars in donations poured into Santa Clara from as far away as Maine. And local physicians were given a big black eye.
The doctors knew the newspaper had published an inaccurate report. The child had, indeed, received free care. So the county medical society launched a campaign to show that physicians there had hearts, after all.
Nearly 100 percent of the medical societys members said they would treat up to three patients per month free of charge. The doctor organization developed a rotation list of those physicians, then ran newspaper ads inviting calls from patients who felt they couldnt afford needed care. Working with county social services agencies, the societys executive director verified each callers financial predicament and contacted the appropriate doctorgeneralist or specialistwho was highest on the list.
In the first two years after the system was launched, only one doctor turned down a request to render services without charge. That time, the next doctor on the list said Yes.
The payoff for doctors was exactly what theyd soughtkinder treatment by the local press. The best evidence of that: On two occasions, the Santa Clara newspaper learned of patients whose conditions were as critical as that of the gravely ill 6-year-old. Instead of spreading the news across Page One, though, the editors alerted the medical society. Both patients got free care.
Theodora Brownfield of Los Angeles had been ill a lot, which meant shed spent a lot of time in doctors waiting rooms. By and large, shed found those rooms, and the people who staffed them, less than comforting. So she aired her complaints in Medical Economics, along with her suggestions for improvement.
"Should the doctors waiting room not be cheerful, light, sunny if possible, comfortable in temperature, and well ventilated?" she askedclearly a rhetorical question. "It is right here that the physician often gains or loses a regular patient. Most people are affected more than they realize by the appearance of a place. If it isnt inviting, they dont return."
She had few kind things to say, either, for the furnishings in most waiting rooms, especially the uncomfortable chairs. "One office I visited prides itself on the small, stiff-backed chairs arranged neatly around the room, probably with the idea of efficiency, but it works quite the other way."
Also on her list of complaints were waiting rooms that werent cleaned regularly or painted often enough, and those with far-out-of-date magazines. But she saved her harshest criticism for medical offices where receptionists displayed little compassion.
"Im thinking particularly," Brownfield wrote, "of one office where the attendant has a hesitant, uncertain manner, and at the same time is abrupt almost to the point of rudeness. My first conclusion was that she is overworked or new in the position. But after a years observation, I have decided that it is her idea of being businesslike."
Brownfields complaints about office personnel went beyond the waiting room. "There is that terrifyingly formal nurse who takes down the patients name and address in frigid silence. Or another attendant, quite the opposite in dispositionthe noisy, slangy one who spends her time chatting chummily with someone else about the details of a case."
All too often, Brownfield said, neither the staff nor the doctor bothered to acquaint a first-time patient with office customs.
"I recall the embarrassment I felt in a large, crowded waiting room when the receptionist called aloud, Your turn. The doctor can see you now. I had no idea which door to head for." She asked the receptionist, who pointed down a corridor with three closed doors and said, "The one at the end."
"When I arrived at the door, I knocked, and the receptionist called out, Dont knock. Just go in." Someone should have escorted her to the examining room, Brownfield noted. When a staff member, or the physician, takes it for granted that a new patient will know what to do, "it makes that patient wish he hadnt come."
James Hendricks. Flashback in Medical Economics.