Ethics Forum

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Letters from Our Readers

We received a few letters in response to the May 2011 Ethics Forum, which asked the question: What is the rheumatologist’s ongoing obligation to care for patients who do not have health insurance or other means to pay for their care? We wish to thank Drs. Block and MacGuire for their thoughtful responses. Especially in today’s climate, it is refreshing to hear from our colleagues who try to provide care for the less fortunate. Keep those letters coming!

Beyond the Bottom Line

The practice of medicine, despite the best efforts of government and industry, still remains more than just a business with a bottom line—at least I hope so.

The patient in question clearly requires the direct care that can only be provided by a rheumatologist and once admitted to the practice of a rheumatologist should continue to be provided under his or her care unless the patient decides otherwise or the rheumatologist can arrange for adequate alternative care, presumably by another rheumatologist, even if the rheumatologist has to donate his services gratis.

We rheumatologists are a fortunate lot of physicians. We are privileged to practice in the interface between startling advances in science and patients who can really benefit from our application of that science. While not wealthy compared to some other medical specialists, we are well enough off that compassion and charity should not be foreign to our patient populations. Do we need a reason to be altruistic? Well here is one amongst many: Me did not get where we are all by ourselves. We owe our success and positions to countless others, some whom we know and can either thank or repay and many others whom we will never know. The only way we can repay or thank them is by helping others through anonymous charity or direct delivery of our expertise without the requirement for compensation. The latter is a tradition for our profession—it should continue to be encouraged if not demanded.

Unfortunately, the problem for this patient goes beyond that of finding a rheumatologist who will care for her. Her poverty precludes her receiving the medications she cannot afford and the laboratory tests that are necessary to ensure the safety of those drugs, neither of which the rheumatologist can be expected to donate. In this case the rheumatologist also should do his or her best to assist the patient in applying for whatever sources for those medications and tests might be available. To me this is the true frustration with caring for the impoverished patient.

Sidney R. Block, MD
Bangor, Maine

Duty to Care

This note is in reference to the question of ongoing obligation for care for patients who cannot pay.

My comments are based on 27 years of solo private practice of rheumatology in a rural area. I work 70 hours a week and make pretty good money. I believe that any rheumatologist today has a duty to care for a portion of patients who cannot pay. I do not have an infusion center, nor do I use a physician extender. I have recently started a electronic medical record.

In my practice I probably take care of 10% of my patients who are unable to pay for my services. If I cannot donate my time to make someone’s life better, then I need to quit now.

I think it is appalling that this individual had to wait 6 months for a visit. We do not ask for billing information when the patients make the appointment. We see all patients without respect to insurance coverage. When they are in the office and we have determined their problem, if they cannot pay, they are not given a bill but they are given a return visit so that we can make sure they get good enough to go back to work.

It has been my feeling for the past 27 years of practice that if I can make someone’s arthritis better, I can frequently get them back to work. Then the individual can get a job, then he can pay my bill. I have made the patient better and have a paying patient in my practice. A little goodwill such as this goes a lot farther than turning away the nonpaying patients.

Just one ongoing, working, busy rheumatologist comment. Today is my long day and began working at 8 AM and I will be home by 9:30 PM.

Anne MacGuire, MD
Casper, WY