Places to practice
"America's best places to practice" [May 18] failed to include Willmar, MN.
Affiliated Community Medical Centers is a physician-owned multispecialty group, 90 miles west of Minneapolis. Reimbursement is above average, benefits are far above average, malpractice is low, and quality of life is high.
Your article about the best places to practice is interesting, but it would serve students and physicians better to write about the worst places to practice. I would warn med students not to consider those places, and place pressure on the state governments to work to correct the situation.
I would like to nominate New Jersey as one of the worst places to practice. The malpractice climate is very expensive, and malpractice attorneys seem to have the legislature in their pockets, so there is no incentive to fix that problem. In my view, the legislature is generally antidoctor. They tax physicians to give "malpractice relief" to obstetricians and neurosurgeons. New Jersey also has a high penetration of HMOs, and in my corner of the state there is a very high percentage of Medicare recipients. If the scheduled Medicare cuts go through, we will take another hit. I would tell any physician in training to avoid New Jersey like the plague.
Morris Brodkey, MDToms River, NJ
I was flabbergasted by the inclusion of Cincinnati in the best places to practice! I left practice in the Cincinnati area less than two years ago due to one of the worst reimbursement climates in the country (by my unofficial survey). I left my practice in north Cincinnati in the very place that consultant David C. Scroggins is recommending. Shortly before leaving I saw a survey that the area, rich in quality residency training programs, retained only half the graduating residents that it had 10 years prior. Undoubtedly this is due to the poor reimbursing environment. In my experience, third-party payers routinely paid less than Medicare rates. I'm not surprised there are a lot of job opportunities in the area.
On the plus side, Cincinnati is a nice city to live in.
Steve Bartz, MDJanesville, WI
Provincetown, MA, at the tip of Cape Cod, would not be an easy candidate for best places to practice. We have a Cape Cod population which is nearly 25 percent Medicare-covered. When the projected 10 percent cuts hit next year, we will be in trouble. The managed care penetration of the state market is high, and provider reimbursement is poor. Coupled with inflated real estate market values, the budget stress of Cape Cod physicians has resulted in a veritable exodus of primary care doctors in recent years.
If there is any reason to truly celebrate practice here, it is the potential for the development of a proposed regional, single-payer universal healthcare plan. Known as Cape Care ( http://www.capecare.info), the effort represents a collaborative group of health and human service providers, people in local government, business and advocacy organizations.
Brian O'Malley, MDProvincetown, MA
A sticky situation
Recently in our hospice program, we had a similar experience to that of internist William Porter ["Death or taxes," May 4].
An elderly gentleman with esophageal cancer was no longer able to swallow but remained lucid. It was nearing the 20th of the month and he requested to be placed on IV fluids so that he would live until the 5th of the next month when he would receive another pension check, which would be enough to pay for his granddaughter's college tuition.
We agreed to carry out his wish after some debate. We stopped his IV fluids on the 5th and he survived to the 25th of the next month. As he neared the end of the next month, causing us to ponder what to do if he asked for more fluids so that he could live for one more pension check, he made it very clear that his wishes had been fulfilled and it was time to die.