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I get calls and letters from my own insurance company suggesting cheaper meds to substitute for what my doctor and I have decided is the best for me. (For restless leg syndrome, they think I should take amytriptiline, for instance. Would you want your family doctor to take this med every night, or how about the driver in the next lane?)

I willingly pay a higher co-pay, but I know many patients can't afford the same, or high co-pays for multiple drugs. But, on the other hand, new, once a day or shorter-course meds are better for the patient's health and the patient is more likely to take them as directed. Most of my decisions are based on the side effects as well as the desired effects. If we harm the patient by our treatment or his treatment is insufficient, the costs will be higher in the long run. And, as low as physician reimbursement is, the extra office visits (or Lord forbid, a hospital stay) will cost much more than the higher-cost drug.

I finally figured out that the way we were trained, with 36 hour shifts and on-call ever 2 or 3 nights, taught us to think differently from nurses, nurse practitioners, physician assistants and insurance bean counters: we think of what could go wrong, what will happen at 2 AM, and the worst that could happen or what will result in a page during dinner or in the middle of the night, and try to plan accordingly.
Insurance companies require doctors to authorize refills and scripts, so why not let us make the diagnosis and treatment plan, as well?

Doctors are demonized for wanting their patients to be able to not pay a copay in order to decouple the relationship and to serve the financial needs of the insurers. Doctors are thought to be criminals for wanting to prescribe a more expensive drug by implying they do it for some kind of kickback. The above are lies and distortions to deskill the doctor, put the insurer in charge and hurt patients more than they know. It sickens me. And most patients go right along with the lie and the distortion. We are losing something precious here.

I get calls and letters from my own insurance company suggesting cheaper meds to substitute for what my doctor and I have decided is the best for me.

I get those, along with coupons to purchase my meds OTC. The one they want me off of is Allegra. My company has 3 copay levels - the lowest for generics, the next level for brand names on their formulary, and the highest for non-formulary drugs. Allegra is not on their forumulary, so I pay the high copay. But they still want me to use something else. My allergy specialist does NOT want me to use something else, I've asked him. This practice of sending me letters and trying to get me to use an OTC drug really ticks me off. We pay plenty for our premiums, and have for years. I see a doctor (including my allergist) about twice a year, and don't have any other health problems. So they oughtta be leaving me alone...

I agree with your comments regarding the training we get as board certified physicians.

I hope we can continue this open discussion for the benefit of the citizens.

You have been caught in a gambit that has been played here in Southern California for several years.

Younger physicians are forced from the market through the HMO contracting pool. When HMO enrollment reaches a particular penetration in the market, sufficient cash flow is STOLEN from the patient-physician relationship BY the hospital/HMO collaborative.

The issue is that federal and state officials in Texas permitted HMO's to collapse the PPO market by offering pie-in-the-sky estimates.

HMO contracts are NOT based upon rational projections or accounting processes. In fact, they STEAL from the physician-patient relationship in favor of giving money to the risk pools controlled by the hospital and the Pharmacy benefits management companies. This results in a collapse of funding to private-primary-care doctors offices, like yours and mine.

Because HMOs do not reimburse according to services provided, you are left bankrupt due to your commitment to moral medicine.

I have been lectured by older physicians who control boards of directors that I need to remove my physician hat and put on my executive hat. I'll do that when hell freezes over.