letters

Enabling the disabled?

I agreed wholeheartedly with Dr. James Glazer ["Disabled … or Otherwise Enabled?" March 2006] until he took out his pen to sign the handicapped tag certification. A few years ago I refused to do this for a patient with arthritis whose situation was similar to that of Dr. Glazer's patient. The rules for certification in our state are very clear (inability to walk more than 200 feet without an assistive device or person), as are the penalties for falsification of reports. I pointed out to the man, a longtime patient, that I knew he was easily able to walk more than 200 feet, as he had recently returned from a trip to China where he had walked extensively. He became very angry, snatched up his form and left. Months later, he returned to the office for routine care and thanked me profusely for refusing to sign his form. He said his mobility had improved tremendously since he stopped parking in handicapped spaces and started walking more. I felt so good when I went home that night. When I'm pressured by patients who don't qualify for a permit, I point out the section of the form that states I could be fined $1,000 for submitting false information.

Anna Meenan, MD, FAAFP
Cherry Valley, Ill.

On parenthood

Dr. Sarina Schrager's article "Doctorhood and Motherhood" [February 2006] hit a soft spot because it comes at a turning point in my life. My husband and I decided to put off starting a family during residency and fellowship. Now that graduation is near, we're looking at job offers, and our choices will be affected by how much of a family life we can expect to have. Dr. Schrager points out that while doctorhood and parenthood can coexist, we should remember our priorities. For us, that is family.

Anna Santa Maria, MD
St. Paul, Minn

Going cash-only

I enjoyed your articles on cash-only practice [February 2006]. I helped create a cash-only practice in Albuquerque, N.M., in January 2005. Our goal is to serve working poor, uninsured and immigrant families needing urgent as well as ongoing care. We have seen a 97-percent payment rate from more than 2,000 patient visits at $25 per visit. We've experienced great enthusiasm from our patients that has spread to their family and friends. My colleagues and I have achieved excellent clinical results and 100-percent job satisfaction. While we earn less in this model, there are no paperwork hassles, no bureaucratic hurdles and no unnecessary employees. We enjoy extremely low overhead, and, because we work part time, we have the opportunity to increase our income doing locum tenens work.

For anyone considering opting out of managed care, I encourage you to make the transition in a way that fits your needs and is right for you. A cash-only practice allows you the flexibility to offer your services at a reduced rate to poorer uninsured patients. In this model, the bottom line does not interfere with your compassion and values.

Andru Ziwasimon, MD
Albuquerque, N.M.

After eight years in the rat race, I opted out of Medicare, canceled all insurance contracts and converted to a cash office on Jan. 1. These changes have rekindled the fire of family medicine for me. While the financial rewards of subspecialty medicine may be greater, what physician doesn't dream of ending the mountain of third-party red tape? Family physicians are in a unique position to do this because our services are affordable on a cash basis. My visits start at $35.

Jaymi S. Meyers, MD
Seneca, S.C.

As a rheumatologist in academic practice, I would love to start a cash-only practice similar to those described in your articles. We need to get back to the basics. Cognitive work is underappreciated and underpaid, which results in physicians trying to see too many patients in a day, getting caught in a vicious cycle of providing an ever-diminishing quality of care. And then people complain that doctors are not professional enough and do not spend enough time with their patients!

The answer is not more certification requirements or stricter systems to improve "professionalism." We are harassed enough as it is. The answer lies in allowing doctors to do what we do best - taking care of patients - while recognizing the value of our experience and cognitive work in the patient-physician encounter. Managed care exists because we physicians allow it to exist. The patient-physician relationship needs to be resurrected without the interference of third parties.

Emilio B. Gonzalez, MD
Galveston, Texas