Doctors Who Care for Doctors

December 21, 1993|By DANIEL S. GREENBERG

WASHINGTON — Washington. -- First the big freebies from drug companies were ruled out of bounds for doctors, thus eliminating the mellow custom of all-expense-paid medical seminars conducted between snorkeling sessions on Caribbean resorts or apres-skis the Alps.

Now, the reformers of medical ethics have trained their piety on one of the most ancient fringe benefits of the doctoring trade, ''professional courtesy,'' the genial term for doctors caring for other doctors and kin of doctors for free.

According to a survey reported in the New England Journal of Medicine, 96 percent of a broad sampling of practicing physicians said they offered free or cut-rate health care to doctors and their family members. The survey found they apparently did so with gusto, for 92 percent of the docs agreed with the statement ''I consider it an honor to care for other physicians.'' The practice was also overwhelmingly endorsed as sound business practice'' and because it ''solidifies bonds between physicians.''

Despite the good fortune of the recipients, and the gratification reported by the benefactors, the team of doctors who wrote the article displayed a strong distaste for the tradition of intramural charity in one of the highest-paying professions.

''It does not seem fair,'' they wrote, ''that discounted care is provided to physicians, who generally can afford to pay for it, when so many Americans cannot afford health care or have limited access to it. Preferential treatment of colleagues seems to be an unjustifiable attempt by physicians to insulate themselves from the rising health care costs that others must pay.''

The survey found that professional courtesy comes with a fiscal quirk that may actually render it illegal. Most doctors, of course, carry health insurance, and customarily these insurance policies require the patient to pay a share of the costs. When professional courtesy is extended, payment by the doctor-patients is waived by the colleagues who provide treatment -- but the insurance company is nonetheless billed for its share of the cost.

''From a legal standpoint, the failure to attempt collection may be fraudulent,'' the Journal article speculated, noting that ''The American Dental Association explicitly states in its code of ethics that the practice of billing only the insurer is over-billing and thus unethical.''

Once these attacks on ancient privilege get rolling, change is bound to follow, as has so often been the case in the culture of medicine. The authoritarian role that M.D.s long occupied in health care has gradually been whittled down by demands of nurses, pharmacists, technicians and other members of the ''health team'' for proper recognition of their skills and contributions.

The tawdry practice of doctors wining, dining and vacationing at the expense of pharmaceutical manufacturers was long defended by the medical profession as just a convenient way of keeping abreast of new drug developments -- the presumed reason for accepting hospitality.

But under the glare of a series of congressional hearings several years ago, the lavish hospitality was revealed to have hard-nosed business motives. In congenial settings, with all the costs prepaid, the drug manufacturers urged their guests to recognize the value of their products and to prescribe them to their patients. A variety of incentives were offered, including ''frequent prescriber'' points for cooperative doctors.

The American Medical Association and the Pharmaceutical Manufacturers Association initially scoffed at the notion that the prescribing judgment of physicians could be bent by a vacation trip or a dinner and theater. But eventually, they were overcome by embarrassment and agreed to a code of behavior that limits gifts from drug firms to inexpensive items, like pens, flashlights and modest dining and entertainment.

Legal or not, professional courtesy is bound to go the same way. Maybe it does solidify bonds between physicians, and clearly it is good business. But in an era when medical costs have `D become a national political issue, not even the wiliest public-relations counselors could work up a plausible defense for doctors getting it free.

Daniel S. Greenberg is a syndicated columnist specializing in the politics of science and health.

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