Published 11/1/2007
Dennis M. Walker, MD

Who’s in charge here?

The question of reimbursement, and more significantly, the question of who controls the practice of medicine in the United States, is one that concerns all physicians. In his response to Thomas M. Hawks, MD (July 2007 AAOS Now), David A. Halsey, MD, encouraged ongoing communication on the issue—and I’m taking him up on his recommendation.

As a medical student, I felt I had little to say and nothing to complain about, but more than 30 years later, with my daughter entering medical school, I had cause to reflect and I realized that I have more to say and much more to be concerned about.

Today, medical practitioners are being subjected to unsolicited and unfounded challenges to their credibility. The ongoing medical liability crisis, unscrupulous and illegal practices by managed care, and, not in the least, the continuous, inaccurate, and misleading rehashing of the Institute of Medicine’s study To Err is Human by politicians, lawyers, and policy makers have done much to undermine the reputation, income, and sanity of medical practitioners. Unchallenged, the onslaught will continue.

Year after year, we accept unkept promises to address these issues from Democrats and Republicans alike. In the past, many of our medical leaders have suggested we simply try again next year, but this is like flipping a coin, in that each year becomes an independent event with no cumulative effect in our favor. This is particularly true in Washington after an election, when incoming legislators claim that they are not held to the promises of their predecessors.

Each paragraph of Dr. Halsey’s response reaches the obvious bottom-line: whether it’s Medicare or the U.S. Congress, no one will take action or respond to our concerns until there is a problem with access to medical care, especially with the Medicare population.

It is my observation that controlling access is a reasonable and provocative way to effect change. Medical professionals have to take back control of the practice of medicine. Following the precepts of Occham’s Razor—that given multiple solutions to a problem, the simplest is the best—I would suggest that we begin to posture ourselves to employ this solution.

There is precedent for this tactic. Physicians in Ontario, Canada, used it when they were faced with even greater burdens placed on them by their socialized medical system. After 20 years of fruitless endeavors, and after educating the general public, they provided coverage for emergency departments, intensive care units, and any acute medical or surgical problems, and simply refused to see any new patients. The Minister of Health and the provincial government capitulated within a matter of weeks. Salary ceilings were raised, surcharges were removed, and additional income taxes, levied specifically at physicians, were abolished.

Physicians are the only people on the planet who do what we do, but failure to respond aggressively and expediently will only allow entrenched factions such as managed care and the government to further undermine our profession.

I’ve presented this option to my medical colleagues locally, but have not been able to offer them a venue through which we might implement this solution. When I questioned the administration of the American Medical Association, I got a political response.

It requires a national body representing medicine or one of its specialties to set the directions for implementing such a protocol because antitrust laws prevent its being done at the local level. Furthermore, disparate groups working independently only make it easier for the powers that be to attack these small sets and diminish their enthusiasm for the cause.

Meeting the challenges presented by the forces mounting this unrelenting attack on the medical profession requires that we as medical professionals engage our patients in the dialogue. Although we must act vigorously and definitively at both the local and national level, we must not overlook or ignore our patients or we will be reminded by both the media and politicians, as well as our patients, that we have done so. We should employ a Madison Avenue marketing mentality. We must avoid Mom-and-Pop rhetoric in response to corporate America. It just won’t work.

I understand that medical professionals have to become more knowledgeable about the politics of the situation, but it does nothing to live in the camp of the enemy if we do not have a game plan in place when we regroup and attack.

Orthopaedists are generally fair-minded and obligatory leaders. More senior surgeons, blessed with more hard-earned wisdom and less call, should make the commitment to engage these challenges, share their insight, and provide the leadership to ensure the future of our noble profession.

I am not speaking out to denigrate the efforts made to date by our leaders in medicine, but rather to suggest strongly that the present philosophy of political small steps will not bring success for many, many years, if at all. I welcome a response and critique of my position and encourage more vigorous discourse on a rapid solution to our collective dilemma.

We must divest ourselves of our egocentric, insular past and come together strongly united. I find it unacceptable that physicians, as a group, would tolerate these ongoing attacks from the government, the legal profession, and managed care, and then appear at the bargaining table without an olive branch in one hand and a hammer in the other. Dennis M. Walker, MD, is an orthopaedic surgeon in private practice in Lake Charles, La.