The following article is presented in the form of an interview with Lawrence C. Pahua, MD, conducted by Guest Editor John M. Freeman, MD.
John M. Freeman, MD: You've practiced pediatrics for 30 years. You've been deeply involved with the Maryland Chapter of the American Academy of Pediatrics (AAP) and served as its president from 1986 to 1989. You have been involved on the national level as well. You were elected Maryland's Pediatrician of the Year in 1989. What do you see as the ethical problems facing the practicing pediatrician in 1991?
Lawrence C. Pakula, MD: I see exploitation of patients as the largest potential problem for the practice of medicine. The number of individuals who do this is small, but their impact is great. Pediatricians don't have many ways to exploit their patients, and by nature they are not exploiting types. By exploiting patients I do not mean obvious fraud, but rather taking up their time unnecessarily, bringing them back to the office for excessive visits to check on their ears or throat without clear-cut medical indications, or creating unnecessary anxiety or inappropriate dependency on the physician's services. I think that these are all forms of exploitation.
I don't think that this problem is as common in pediatrics as in some other medical specialties. Pediatricians are not necessarily more honest than some other physicians, but they have less opportunity to exploit their patients. There is less access to things that make it possible to be profitably dishonest. I'm well aware of a few pediatricians who were billing Medicare for throat cultures that were never done or were done on well children without medical indication of need and appropriateness. However, I want to emphasize that I think these were rare events.
Freeman: I have the impression that children, perhaps all patients, are having many more "routine" tests performed on them today. Are they being done mainly for the physician's financial benefit? For example, I go to my internist and he sees me for maybe 5 or 10 minutes, and I'm charged $60, but he also gets a blood count, EKG, and often a chest film, and interprets them all. The bill ends up as $120 for tests (which Blue Cross pays), and $250 for physicians visits and interpretation (most of which Blue Shield pays). Is that good medicine? Modern medicine? Or just remunerative medicine? You were trained in "the old days," when tests weren't quite so easy to obtain in your office, and when you, and physicians in general, weren't compensated for performing them. When you compare your current approach to pediatric practice with that of people trained more recently, in the era of "laboratory medicine," do you see a difference?
Pakula: Very definitely. When I started practice, if I wanted a hematocrit or a hemoglobin I did it myself. Urinalyses too. I may have charged 50 cents or a dollar, just for the record-keeping part. When treating children, we mostly relied on the history, the physical examination, and our past experience to make diagnoses. This was called "clinical judgment." We did many fewer tests. Laboratory tests in the office were difficult and time-consuming - they weren't moneymakers. Those are probably the main reasons so few were done.
Younger physicians, during training when tests are easier to do and far more available and reliable, are expected to use them in evaluating patients. They come to realize that it is often less expensive to order a "panel" of tests than to be selective. It may be that they are now less secure without "the numbers." Some families have learned to expect numbers and don't seem to respect medical opinions without numbers to back them up. Some tests are done because they give the appearance of legal legitimacy. Most realize that there is an element of profitability in the tests. What the pediatrician may not realize is that any or all of these may be factors in the increased testing. In our practice, we do not receive personal financial rewards for the laboratory tests we order. All laboratory income goes back to the practice. I feel very strongly about that. The physician shouldn't be rewarded for the tests he or she orders, but only for seeing patients. I am aware that there are other practices where there is direct reimbursement to the physician based on the utilization of tests.
These issues are rarely discussed by physicians or organizations such as the AAP. There is a tremendous fear that the discussion of fees and practice patterns might be interpreted as antitrust violations. They are aware of antitrust suits directed against obstetricians in this regard, which have been expensive and time-consuming. Most of us would be helped if there were some sharing of information regarding practice patterns.
Freeman: You are aware, then, of some pediatricians who do too much testing, cause too much anxiety, bring patients back too often, perhaps because of their lack of information or because of their lack of security, or perhaps in some instances, because it is more lucrative to do so. Yet you, as an ethical physician, and the Academy itself, do nothing. Should that be an ethical concern? You say that it's not even discussed. Why not?
Pakula: My guess is that such a discussion might split away a group of people who might be termed "more entrepreneurial." I think that it is very difficult to discipline our own, except when someone is very, very far out of line. It is even hard to draw the line across which one should not step. You might be hard pressed to find a pediatrician who would sit in judgment on his or her peers unless there was a specific or a significant complaint from a patient or some legal authority. If there was such a complaint, then I would certainly be willing to look into it under the auspices of some group with authority such as the Maryland Board of Quality Assurance. Most of my colleagues, however, don't know and are afraid to know what is going on in somebody else's practice. If they are aware of overtesting in their own practice, then they rationalize that what they do in their own practice is better medicine. If they found out otherwise, then the rationalizations might collapse.
Freeman: Is there an ethical problem here? What should our pediatric colleagues and our medical societies be doing about this?
Pakula: I think that there is both an informational problem and an ethical problem because we do not know patterns of practice and what should be considered the norms. This information is known, for example, by the insurance companies, but it is not shared with us as individuals or with our professional organizations. I think that this is a major ethical issue. Some health plans have similar information, but restrict it for competitive reasons. When medical students and pediatric residents come through the office, I try to impress on them that we have to justify to ourselves everything that we do to and for our patients and that we have to justify our decisions to others if necessary. I wonder if they are told the same things in the clinics and on rounds at the hospital?
What I mean by justification is that the care and the testing of our patients clearly has to be for their benefit. It is easy to take advantage of your patients. They have faith in you. They expect you to be ethical and moral, in addition to being well-trained. They expect you to do the right thing. I hope exploitation happens a lot less often than the general public believes it does.
There is a problem in the reimbursement system, which pays far more for tests and procedures than for the time physicians spend applying their knowledge and skills. "There is little compensation for the time spent thinking and worrying about the patient or about tests that have or have not been ordered. There is no compensation for the time spent explaining to the parent why you are not ordering expensive tests or making expensive referrals. If you "own" the tests or the procedures you are ordering, then there is a conscious or unconscious incentive to use them. You can always justify this to yourself and to the patient as being "more thorough," "more comprehensive," or "more up to date," but are they necessary? Are they a part of good medical practice or better medical practice? Fortunately, pediatricians don't have the temptations of some of the higher-paid specialties; it takes a lot of throat cultures, urinalyses, and CBCs to equal one magnetic resonance imaging (MRI) scan or colonoscopy. I think that the AAP has recognized this and has supported the relative value scale initiative. If this system works, it should be of real value to both patients and physicians.
Many nonmedical people and many groups who deal with physicians look on medicine as just a business. If that is the way physicians are to be treated, then why not act more like business people? Why not be a part owner of an MRI scanner? Why not have the lab in your office? It could be rationalized that "The child will receive better care," or "At least I know I can trust the quality of the work." You can rationalize that "I have to send my patients somewhere for their tests, and my facility is more convenient for them." If we could be sure that we weren't going to do things unnecessarily, then these aspects of revenue generation would not be a problem. But, we are supposed to be professionals, not businessmen. Investing in these diagnostic facilities is like the airlines' frequent flyers programs. Investing may bias your choices, at least that is what the airlines' hope. You might not have flown Delta to the meeting, but since you already have some miles and because it is relatively convenient to do so, you do. And thus, your choice of airlines is influenced. It could be the same scenario when physicians profit from the tests they order. Pediatricians could say to themselves, "It's relatively convenient, and it might be useful, and the patient's insurance will cover most of it anyway."
Freeman: Are these issues ever discussed?
Pakula: I've heard many discussions about the "big" ethical issues, about abortion, death and dying, and do not resuscitate, but not about the business aspects of practice. What would happen if a group of pediatricians were to get together to discuss the business parameters of their practices? The fallout of such discussions could be devastating to the lives and practices of those pediatricians and their associates. The discussions are needed, but the pediatricians are afraid to talk.
Freeman: What do you see as "the big ethical" challenge in the practice of pediatrics?
Pakula: I would say that it is maintaining appropriate patient-physician relationships. One of the major changes that I have seen over the years is the change in physician attitudes toward patients. Patients aren't as loyal as they once were. They are more mobile, and insurance companies or health maintenance organizations (HMOs) make them change physicians more often than in the past, so patients can't be as loyal, even if they wanted to. Unfortunately, physicians' concepts of their responsibility to their patient is not as great either. Too often the responsibility is expected to fit into a 9-to-5 relationship. Physicians trained more recently often don't know the rewards of a physician-patient relationship that extends over many years. I see it breaking down more and more. Both the physician and patient suffer when this happens.
I'm beginning to sound ancient, but I think that the relationships were better 10 or 15 years ago - better for me as a physician, but also better and closer for the patient. I can still pick out the student or resident who is likely to develop those relationships. That "old fashioned medicine" may take some toll on the physician and even on the physician's family, but the rewards are worth it. We have to talk more about the satisfactions of practice. Students and young residents are often afraid of the possible impact such relationships will have on their families and on their lifestyles. I thought my practice took its toll on my family life, but now that I think back on it, if I had had an extra hour or even 2 each day to spend with my family, Pm not sure things would have turned out much different. I have a wonderful wife and a close relationship with my children and their spouses and with their children. That extra hour or 2 couldn't have made things that much better.
All my life I have been told that you have to work hard and that was how you got your rewards. It's not just the volume of work, but rather the quality of the work that counts. I tried to get home every night to have dinner with my family, and then I would go back to make hospital rounds. Practice in an HMO may give you more control of your life, but I think it brings fewer rewards gained from the intimate patientphysician relationship. Perhaps there are different rewards and perhaps different rewards are appropriate for different people, but I believe that the patient whose physician is less involved in his or her care doesn't get as good care as the one whose physician is more involved.
Freeman: Does it ultimately make a difference? Is the child whose pediatrician is more involved healthier? Happier? Is the family ultimately more satisfied? Can you demonstrate a difference?
Pakula: Probably not in any formal, statistical way. We are beginning to demonstrate that parents do listen to pediatricians and respond by action, but often we have trouble proving that what we do really helps them. 1 think that both the family and the pediatrician will miss out on what may be the greatest reward of practicing medicine, that is, the intimate involvement in each other's lives. Most important are the human, social, psychological, and developmental dimensions of the patient-physician relationship. Seeing the child and family during times of illness and of stress is as an important part of building that relationship as is seeing them at well-child visits. I guess that a part of the reward comes from the social work aspects of medicine. But if physicians are not there when their patients need them, then the patients will soon learn that they don't need physicians, per se, and both the physician and the patient will lose out.
I'm concerned about the pressures on physicians in general - the peer pressures, the legal pressures, the administrative pressures, and the economic pressures. I'm less concerned about the ethical pressures - at least in the field of pediatrics. I just don't want students and residents to miss the enjoyment that I've had from working with my patients and their families. It's not hard to be ethical under these circumstances. I'd have to look hard to find ethical problems in my practice.