Letters to the Editors

December 3, 2004

Can e-mail visits pay off? Admitting that you don't know; The economics of boutique medicine.

Can e-mail visits pay off? Expecting health insurance carriers to pay for e-mail consultations ["E-mail visits can save you time," Sept. 17 http://www.memag.com/memag/article/articleDetail.jsp?id=123705] seems a bit pie in the sky when our reimbursements are being cut to the bone as it is.

Gregory Hood, MD

Lexington, KY

Judy Bee

La Jolla, CA

Admitting that you don't know While I fully agree with family physician Richard E. Waltman that it's okay to admit to a patient that you don't know what's wrong with him ["It sounded like a good idea at the time," Sept. 3 http://www.memag.com/memag/article/articleDetail.jsp?id=120982], it won't always work.

In my first year of solo pediatric practice, I saw a young patient who had had urticaria continuously for more than three months. Aware that this could be a sign of very serious disease, I told her mom that I'd do some reading and call her back later with a plan of action. When I did, she informed me curtly that she'd left my practice and found another pediatrician. She told me she'd never let her child be cared for by a doctor who didn't know everything.

Back in those days a lost patient really hurt, but my ego survived the insult. I still admit to patients when I don't know the answer, but I remember that, for some of them, looking in a book is a sign of incompetence.

Stephen Jacobs, MD

Modesto, CA

The economic impact of boutique medicine FP Robert M. Pallay's eloquent contrast of boutique medicine and the plight of 41 million uninsured Americans ["The country can't afford boutique medicine," Sept. 17 http://www.memag.com/memag/article/articleDetail.jsp?id=123427] gets to the heart of what your magazine is about: medical economics. It's the age-old conflict of micro- and macro economics.

But the issue of medical care for the uninsured is a matter for the ballot box, not the individual practice. When the healthcare system becomes intolerable, the voters will do something about it. Meanwhile, physicians who want to do the most good should earn as much as they can and pay the taxes that will support the safety net for the most needy. As for the more than half the families without health insurance who have incomes greater than $75,000, if they choose to spend their money on things other than healthcare, they are gambling in a high stakes game, but it's the American way to let them do so.

The British are well aware of what paternalistic healthcare is like, and there is a thriving private medical economy there. I, for one, am glad that working stiffs like me and not just the "carriage trade" have someplace to go other than a public health clinic.

Jeffrey J. Denning

La Jolla, CA

What an ironic juxtaposition! The appearance in the same issue of the opinion piece on boutique medicine and your annual earnings survey, "Primary care tries to hang on." It seems that doctors are coming to boutique practice from the same fields where practitioners are barely hanging on.

Many doctors who had been trying to hang on to the primary care cliff have already fallen off-right out of practice. But at least the boutique doctors are remaining in business, and are still caring for thousands of patients. They're even finding time to do volunteer medical work. But can they stem the tide? Without a large and satisfied group of primary care doctors (or other caregivers), the future of healthcare is bleak.

I. Scott Hall, MD