AAOS Bulletin - February, 2006

Letters from our readers

Physician work stoppages

I must respond to “Should surgeons join work stoppages?” (Bulletin, December 2005). I am disappointed in the Ethics Committee. I agree that there may be circumstances that could justify a physician’s work stoppage or job action, but these are rare and should be specifically directed toward making patient care better. Unfortunately, Dr. Hill did not provide justifiable reasons for physicians to join a work stoppage or job action.

Dr. Hill, with the committee’s endorsement, says that it is Medicare, managed care, medical liability premiums and insurance companies that have caused the problems we currently face and that have altered the practice of medicine. He says these conditions justify a change in our ethical standards. I cannot find any evidence that there is justification for changing our ethical standards, nor do I think work stoppages or job actions have or are likely to improve patient care. Work stoppages and job actions are designed to help the worker.

Managed care companies do not dictate care. They decide what treatments they will pay for and how much they will pay. We are free to provide all the care we want. Managed care companies do not determine fees. We are free to set our fees. We are not forced to accept their terms. We decide if we will sign a contract with them. We can even opt out of Medicare. We are the ones who have made the practice of medicine more like a business. We have rationalized keeping MRI ownership and contracts with implant manufacturers hidden from the public. Look at the AAOS Annual Meeting program.

An increasing number of us face conflicts of interest because of our relationships with industry. An increasing number of courses are related to the business of practice, which are heavily attended. Courses that focus on learning how to communicate with patients, how to treat osteoporosis and nonoperative treatments are less popular. Unquestionably, to have a successful practice, it should be managed like a business. But work stoppages and job actions to pressure third-party payers to pay us more are not justified.

Dr. Hill implies that orthopaedic surgeons are being forced out of business, but we are doing quite well financially. The median income for a surgeon in the United States is $320,000. Compare that to the median income for a family of four in the United States ($65,000), a lawyer five years into practice ($80,000) and a lawyer 15 years into practice ($184,000). How can we complain that our situation justifies a work stoppage?

Tort reform may be needed, and this debate is ongoing. Physicians should be politically involved and should help elect officials who will come up with solutions. But going on strike to force government to restrict the insurance industry or the legal profession while complaining that we want less government intervention seems hypocritical. Anesthesiologists have reduced their malpractice cost by improving the quality of care provided. Maybe we should do the same.

The Institute of Medicine, in its 1999 study To Err Is Human: Building a Safer Health Care System, reported that much of the care provided results in damage to patients. Maybe we should stop operating until hospitals are organized to reduce these injuries. Maybe we should be on a job action until our peer review committees are empowered to discipline physicians who practice below the standard of care. Maybe we should stop working until all, or at least most, treatments are based on scientific evidence. That would do more to improve patient care than a job action to pressure third-party payers to pay us more or to allow us to waste resources.

We need to examine ourselves, our profession and our “new” ethics. The front pages of The New York Times (Sept. 22, 2005) and The Wall Street Journal (Dec. 12-13, 2005) have revealed how our ethical perspective may be out of focus. We took an oath and we chose to be physicians. The ethical standards for physicians are different from those for nonphysicians and there are good reasons for this. Patients give us the privilege of caring for them. They allow us to invade their bodies and to risk their limbs and lives, and we must protect the patients by following strict and demanding ethical standards. A work stoppage or job action that is designed to improve our lives—even when disguised as an improvement in providing patient care—will always be unethical.

Dempsey Springfield, MD

Stamford, Conn.


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