In an early Peanuts cartoon Charlie Brown asked Linus what he wanted to be when he grew up, and Linus replied that was going to be a country doctor: “Yup. I want to be on the right side of the ol’ needle.” That’s probably as good a reason as any to become a “professional man.”
At this time, when the idea of being a “pro” encompasses anyone from waiters to hair-dressers to river raft guides, it is useful to recall how the idea of a professional originated.
It was not until medieval times when universities were first being organized under religious auspices that the three Classical or “learned” professions emerged: the law, medicine, and the clergy. Each profession filled a valued role in society, and, accordingly, each was awarded prestige, status, and power. All three professions required long study to join their ranks, and all were governed by codes of ethics. The ethics of medicine were rooted in the oaths of Hippocrates and later Maimonides. Incorporated in those codes was the principle of respecting one’s teachers and colleagues,which included the granting of “professional courtesy,” by which one physician wouldcare for another (and his family) without charge. Both my family and I have been benefited from this tradition, but recent reports from other doctors suggest that professional courtesy today is honored more in breach than in fact.
My first act of professional courtesy came shortly after I entered practice. I was responding to the request of an older internist acquaintance who wished me to operate on his wife for unsightly symptomatic unilateral varicose veins. Truth be told, the symptoms were minimal, but the veins were so large that I confidently anticipated a very good cosmetic result, and this proved to be the case. I was proud just to be asked, since he could have asked any one of a number of vascular surgeons in our community, but he asked me.
In those days patients stayed in the hospital for 2 or 3 days until they were walking comfortably and unaided without limping. Within 2 weeks, my patient was free of bruising and fully recovered. Whether she or I was the happier with the outcome is long forgotten, but I recall receiving a small gift for having extended “professional courtesy.” When her husband told me that he would rather I just sent a bill I replied “Absolutely not.” I saw it as my duty — I was probably too young to say “solemn duty” — and indeed my honor to be able to care for his wife. He had medical insurance, of course, and I could have billed for the procedure, but I didn’t.
Looking back, it might have been the first of countless occurrences where the insurance company came out on top when dealing with doctors. In not accepting the insurance was I invoking professional courtesy or merely self-indulgent hubris?
In ensuing years I have been priveleged to operate on and care for many doctors and their families. Other specialists, such as pediatricians, internists, and psychiatrists, have long-term and ongoing relationships with their doctor-patients that are less “one off” episodes than is usually the case with surgeons. For these kinds of specialties, providing “professional courtesy” may be a greater financial burden than for surgeons. Each doctor must decide for himself whether to charge for services rendered to a colleague or their family.
Insurance coverage is approaching universal and not to charge the “third party” insurer is, arguably, foolish. Insurers would mock us if they knew we elected not to bill by virtue of some lofty motivation. In the case of Medicare — thanks to laws designed to prevent kickbacks and patient solicitation — it is illegal not to bill a patient of any sort, including doctors. Even if one bills Medicare, one is additionally required by law to balance bills for the 20% of the bill that is not covered.
If the age of professional courtesy is past, how should we conduct ourselves in the future? Is professiona courtesy an anachronistic gesture that should be allowed to expire quietly?
The answer is not straightforward. What was once an arrangement between two people –a doctor and his patient, who incidentally was a doctor — now includes many other participants tocomplicate the basic gesture. If a person has insurance, it seems wasteful not to bill for services.
Inded, a decade after the passage of the Medicare Act in 1965, the elderly went from being the worst insured group to the best iinsured, and Medicare patients were the vascular surgeons “target clientele.” Fees and “real income” for procedures were also higher then, and were in 1970’s dollars. In those years, if those with poor insurance, or no insurance at all, couldn’t afford treatment, then surgeons commonly waived part or all of their fees. It was a simpler time.
Today, as we haltingly stumble towards “universal coverage,” acts of charity and professional courtesy both appear destined to disappear. I would guess that other aspects of how doctors behave towards our patients will likewise face a major overhaul. And it won’t make any difference what side of the needle you’re on.
Dr. George Andros is the medical director of the Amputation Prevention Centery, Valley Presbyterian Hospital, Van Nuys, Calif., and the outgoing medical editor of Vascular Specialist.