This paper serves as a companion piece to the article “Pay, Pride, and Public Purpose” by Altom and Churchill, which argues for universal access by appealing largely to the self-interest of physicians.[1] The authors of that paper do not make clear whether they see “universal access” as being single- or multiple-tiered nor as to whether such access would be funded through general taxation or remain in private hands. Further, they argue that physicians ought to help bring about universal access for what amounts to reasons of “self-interest.” The ideas behind reasons of self-interest are varied: the satisfaction of knowing that all sick who come to you receive the same kind of treatment, insured or not; and knowing that we live in a community in which we care for one another as a matter of course – a community that sees the motivation for the Constitution to be to “establish justice, insure domestic tranquility, provide for the common defense, promote the General Welfare and secure the blessings of liberty.”[2]

There is no question that in the 1940s, '50s, and even '60s, physicians frequently opposed reform in the then current and largely private cottage industry system.[3] Allegedly physicians feared the loss of professional as well as economic autonomy. As a matter of fact, much of the opposition to allowing physicians who were refugees from Nazi Germany into the country resided in the fear that they would bring along what American physicians called “socialized medicine” (a label they erroneously applied to anything that wasn't fee-for-service!). But that has changed significantly.

Every “specialty society” I know favors – and most have put forth – a plan for universal access. The AMA Code of Medical Ethics states: “A physician shall support access to medical care for all people,” which is precisely what universal healthcare is. The rather large Physicians for a National Health Program (PNHP) has thousands of members across the nation and is active with the public, the legislature, and the profession. At the very least it has stimulated discussion within the lay press and the public at large, and has even influenced some Republican lawmakers to see that something must be done. Ironically, the only society dealing specifically with healthcare matters that has refused to take a stand is, of all things, the American Society for Bioethics and Humanities (ASBH) and its 3 historically separate predecessors. For at least 20 years (until I finally resigned in protest several years back) I used to rise yearly at these societies' general meetings to suggest taking a stand on what I have long called “framing conditions” – “framing” because without them little else makes sense.[4] The excuse has been that our bioethics societies' constitutions expressly forbid us to take such a stand.

And then it happened: One of our members was unjustly treated by her university and, because of our constitution, we were apparently restrained from speaking out. This became an interesting quandary, for if we as a society condemned such treatment we would, in effect, be taking a stand. After prolonged debate, the matter was brought to the Board and a vote of the general membership was sought. The members voted that we would speak out, but only on matters such as academic freedom, tenure, etc. In other words, we would speak out on only those matters that directly concerned us personally. The vote was purely self-interested, and one that clearly expressed the sentiment “I've got mine, the devil with you.” This is why, after 20 years of pleading with the society to take a stand on poverty, hunger, lack of opportunity to develop one's talents (all closely connected with the incidence of disease), and access to medical care, I resigned. To be a bystander to conditions that could in fact readily be changed is to make oneself guilty as an accessory to the fact – precisely what the deafening silence of academics (by no means only in medicine) in Nazi Germany did.

When I hear that physicians should do more to bring about “universal access,” I can only ask what more Medicine can do than take a personal stand, support that stand within its societies, and have its lobbyists support it? After all, the particular group of physicians specialized in the area of their interest assembles predominantly to hear of new insights, diagnostic methods, and medical or surgical treatments; it does not assemble primarily to lobby for social justice, universal access, and other sociologic problems. We forget that physicians are not trained in, nor should they practice, social engineering. They already have numerous obligations: (1) to keep abreast of changes in their field; (2) to do the best job in their areas of competence and to refer those with medical conditions outside those areas to a physician with such expertise; (3) to point out “system errors,” ie, suboptimal medicine that exists as a result of some persistent fault in the system; and (4) to try to have their voices heard regarding social issues which affect their patient's incidence of disease and/or access to care. One would think that bioethics organizations would be even more interested than, say, the AMA in bringing about an ethically acceptable system in which quality medicine – both ethically and technically – can be practiced. The AMA, for example, in the ninth and final point of its “Principles of Medical Ethics,” requires physicians to “support access to medical care for all people,” while the ASBH has remained silent.[5]

In this article I will (1) give some definitions – not because they are necessarily correct but so that we are all “on the same page”; (2) attempt to refute the claim that the majority of physicians are predominately motivated by self-interest; (3) examine what interplay of circumstances motivates physicians; (4) grapple with the question of why the United States fails to have an ethically viable healthcare system; and (5) provide a short summary and some suggestions.

Different people may define differently the words for which I will offer definitions. In order to have a meaningful discussion about a subject, however, we must first agree on the definition of keywords for the sake of that particular discussion; if we do not, our discussion becomes largely meaningless. For the sake of this or any article, we need to understand what the author means when he/she uses a key term. Therefore, I merely offer these definitions for this article at this time, and am not claiming that they are correct or universally accepted.

“Socialized medicine” (often confused with single-payer medicine) means that everybody in need of a certain diagnostic or therapeutic modality will receive it and no one can buy more. By “more,” I do not mean luxuries like single rooms, a television, or a bottle of wine with dinner, but things which contribute to the outcome: the same diagnostic or therapeutic modalities, the same waiting time, etc. Examples of this are Canada, the United Kingdom, and the Scandinavian countries. Other countries with single-tiered universal access are usually handled by insurance schemes tightly controlled by the government, and which do not differ greatly from one another.

“Single payer” means just that: A monopoly (be it state or private) pays for the services rendered. It is not – as the Clinton plan claimed it was – identical to single-tiered. For example, a single payer can pay for a “multiple”-tiered insurance offering a wide variety of plans. A single-payer system is like a musical instrument that can play many tunes.

“Multiple-tiered access” means that everyone gets “basic” care but those better off can buy additional insurance which will care for more, have shorter waiting times, etc. – things that surely affect outcome. The argument for this scheme goes something like this: If a person values expensive vacation trips or other luxuries more than health services, why should they not put their extra dollars into what they value instead of into what they don't? Further, why should those who are thrifty pay for the medical care of the profligate? There are several fallacies in this argument: (1) One rarely values expensive medical care until one is in need of it; (2) I may have been equally diligent and thrifty but have made a much smaller income. My choice was not between a yacht and supplemental healthcare but between supplemental healthcare and helping my children through college. And, most important, would you really want to live in a community in which your neighbor who does not have access to an expensive procedure dies while you live? Essentially this means the death penalty for both those who are poor and those who have been wastrels.

“Universal access” means that all people within our community have free access to physicians, laboratories, x-rays, and other diagnostic and therapeutic modalities regardless of their ability to pay. Universal access is not “universal” if patients must pay a copayment that is beyond their means. A brief story by Dr. Miles who was asked this by a neighbor (presumably not living in a poverty area) exemplifies the problem:

“Capitation” is meant as a retreat from “fee for service” to a schema where a physician receives a given sum of money for each patient “registered,” irrespective of whether s/he sees the patient 100 times or not at all. Capitation is used by the British and in the Scandinavian countries. The feared “abuse of the physician” – whereby patients flood the waiting room with minor problems for which they would have otherwise never seen a physician before – has not occurred. This is quite readily understandable. Going to visit a physician is not most people's idea of a pleasant afternoon.

To me, then, universal access means “single-tiered access” – perhaps with a copayment but one that is adjusted to the patient's income and which has a ceiling. If it were to be “multiple access,” it would have to be called “universal basic access with varying additional options.” That is what the ill-starred Clinton plan would appear to have been. The complexity of that plan would have required a tremendous administrative input, which is precisely what we want to reduce. Moreover, a health plan is a tremendously complex thing. To create such a system in “100 days” is totally unrealistic. Formulating and then thoroughly discussing the essential questions and its consequences takes far more than 100 days and, as with most things of this sort, must always be considered a “work in progress.” On the other hand, America has one great advantage: We are so far behind that we can study healthcare systems, avoid the mistakes of others and, hopefully, create something which fits into our culture...and we must let experience guide us.

A “right,” as Dr. Churchill put it long ago, more often than not is used as a trump card.[7] I shall avoid using that particular term and will use “claim” instead for the following obvious reasons: Six people may have a claim to one thing but the “claim” of one of those 6 may have far greater weight than the others. But if 6 persons have a “right” – as we use the expression – to the same thing there is a true dilemma. Moreover, speaking of a “right to health” is obvious nonsense; whether we are healthy or not may be very much influenced by our genetics as well as environment and social factors, and is also very much dependant on sheer luck. However, saying that we as a society of many skills should create a “universal healthcare system” because mutual help is the cement that holds societies together is a different thing indeed. Here, physicians, as experts in the field of healthcare, who have seen what lack of access or access too late has produced, should most certainly have their voices heard.

An “obligation,” although frequently used interchangeably with “right,” can be negative and absolute. Kant speaks of “perfect” or “absolute” duties, all of which are negative – not to lie, steal, murder, etc. They are “perfect” because one can always refrain from doing so. At this point it could be construed as being “libertarian.” Kant foresees this when he speaks of “imperfect” or “optional” duties – duties one cannot always discharge but which one, in order to live an ethically proper life, cannot refrain from altogether.[8] It is here that a strong divergence from “libertarianism” occurs. For the libertarian, “imperfect duties” are simply not duties; at best they are supererogatory and in many ways are virtually aesthetic. For example, in a very individualistic and capitalist world you will not be allowed to knock me down but neither are you obliged to help me if I fall down. Our laws show the differences in world view: When I fall down in the United States and a policeman sees you walking by me without coming to my aid, you are not going to have any legal problems. In the European Union (EU) you would be arrested for “failing to come to the help of someone in distress” and you will have committed a felony.

Some years ago a superb paper (which I do not agree with at all but whose author's scholarship I admire) claimed that illness for the most part is unfortunate, but because a particular person was not directly involved in causing it s/he has no obligation to help the person thus afflicted.[9] The same author claimed in a paper published in The New England Journal of Medicine that healthcare ethics emerges from entrepreneurialism, and indeed a community is underwritten by entrepreneurialism.[10] I believe that he has turned the pyramid on its head: Entrepreneurialism cannot be the foundation of community (you first must have a community in which to “entrepreneur”). Healthcare – both historically and as understood today – is one of the “helping professions.”[11] Healthcare ethics is generally understood as protecting the patient and not physicians, hospitals, or ethicists. The view that, as long as s/he is technically competent, a physician's primary motivation is self-interest actually goes back to Galen. Pellegrino has called Galen's and Engelhardt's stance an ethic of “outward performance” vs that of Scribonius Largus and what we ordinarily understand by ethics as an “ethic of inward intention.”[12]

The problem is that no one can know what one's own “good” is, let alone that of another. For the Utilitarian the outcome is what makes an act or a rule “good” or “bad”; for the deontologist it is the intention. Yet “outcome” is a poor measure because it is unclear what we mean by it, as well as who is saying it: The oncologist? The patient? The community?

That self-interest – conscious or sub-conscious – plays a role in every person's behavior and, therefore, also in physicians' is beyond doubt. But a larger patient load is hardly a motivating factor for most physicians today. Rather, the main complaint today is a lack of time to devote to the proper care of patients and to their own families, outside interests, etc. Indeed, we in the humanities have steadily decried the fact that physicians seem to immerse themselves in medicine to the exclusion of all else.

Moreover, physicians, like all other people, are motivated by not one but several factors. Their choice of medicine as a profession may be prompted by a variety of things but there are few physicians whose motivation is purely – or even largely – material. There is no doubt that if someone is interested in pursuing a particular profession or field that entails a relatively long and expensive preparation, the question of being able to live a comfortable life, to have sufficient time with one's family, and other material conditions most certainly will (and should) play a role. Yet, for example, it is interesting that in the Soviet Union of old there was still a huge number of applicants to medical school despite the expectation of a ridiculously low salary. Since the fall of the Iron Curtain, physicians' salaries there are still inadequate but there are still more applicants than can be accommodated. In many of the former nations allied with the USSR this is still largely the case – and yet the number of people clamoring to get into medical colleges has not declined.

Physicians are motivated by many things, among which a genuine interest in a particular specialty and being of help to their fellow humans loom large. Many who are motivated to go into underserved areas when they enter find that motivation still undiminished when they leave medical school. Physicians have not taken an oath of poverty, chastity, or obedience but they have taken an oath to “strive to change laws that are contrary to my profession's ethics and will work towards a fairer distribution of health resources.” The AMA Code of Medical Ethics contains the following sentence: “A physician shall support access to medical care for all people.”

Throughout my rather long professional life – first in medicine, and now in bioethics – I have met many physicians who have worked hard and expect a considerably greater than adequate lifestyle, which is not unreasonable when one takes into consideration the fact that physicians, on average, work about 80 hours a week...and many a night. I have met many more who wanted to help their patients and even more who were driven by an urge (not related to money) to excel. These were true “workaholics.” I had a colleague elsewhere whose hobby was reconstructing old cars. But he was a cardiac surgeon and was so busy that he finally hired a person to do his hobby for him! On the other hand, I know several who spend 2 or 3 months a year in underdeveloped countries under miserable conditions doing what can be done for their patients. I have known 2 plastic surgeons (they were often accused of being “greedy”), orthopaedic physicians, internists, pediatricians, cardiologists and others who spent 2 or 3 months a year in medically underserved and poverty-stricken countries. And I have known others from all over the world who often paid for their own fare, food, and living quarters. I have also known those who fought for civil rights, for universal health insurance, and for an equitable distribution to all. Of course, I have met physicians who are crassly self-interested, “greedy,” if you will. However, there were then – and I find no reason to suspect otherwise today – far fewer in medical practice than one finds in other professions.

That people (and physicians are people) wish to have a comfortable living, pay off their debts, help their children through school, and provide for their old age is not a sign of crass self-interest, but one of responsibly providing for one's family and oneself. I do not believe that such a self-interest (defined in monetary terms and going beyond the motivations mentioned) is an important motivator nor is it at the root to the objections to managed care. Physicians' objections are focused, rather, on the constant interference with diagnostic and therapeutic needs; the amount of paperwork which badly cuts down on their ability to take care of patients and, in an academic environment, to teach; and the knowledge that many of their patients will not be able to buy their medications because of their inability to afford ever-rising copayments. Their main worry is that, in our ever-larger MCO-driven market, they are not allowed sufficient time needed to make a decent diagnosis, do not have enough time to get to know their patients, and are restricted in what they are allowed to order: tests, x-rays, consultations, or medications. Worst of all, they, who have pledged not to allow economic circumstances to influence their medical decisions, have often been carefully shielded from the problems of the uninsured or poor patients, who are sent away by some secretary without the physician ever seeing them. Here, at least, physicians united in a like-minded group certainly may be able to do something.

Certainly physicians (and in my view properly) are interested in making a sufficient income to pay their debts, help put their children through school, and provide for their old age. This is not only true of physicians; it is true of all people. Physicians expect, furthermore, to be able to live the way the middle or upper middle class live. That seems to me not only to be expected but prudent. Are there physicians who are as crassly self-interested – perhaps “greedy” is the more apt expression – as the example that Altom and Churchill provide? Undoubtedly, but I think the more important question here is why any of us should think the example of “conspicuous consumption” is ever ethically supportable, irrespective of whether it occurs in a physician, a corporate CEO, or an NBA star. Why should we find it more offensive to find an example of “conspicuous consumption” in a physician than in a CEO or an NBA star or an attorney? Especially in the United States today, it should be worrisome wherever it occurs.

Personally, and having looked through the literature on the subject, I find that the income of physicians has steadily declined (a drop of 7% while other professions have risen as much as 7%)[13] and that the income and fringe benefits of nurses have risen steeply from a time when salaries were scandalously low to today, when some nurses make as much as some physicians and, in many cases, receive far better benefits. Further, if we are to compare income fairly we need to take into account the number of hours involved. Nurses work nearly half as many hours as the average physician does, which makes the difference even more pronounced. In addition, when nurses work longer they ordinarily get overtime whereas physicians do not. It takes a physician (depending on the specialty) 12 to 18 years of training beyond graduation from high school, whereas the average nurse need complete only 4 years of training beyond high school and if he or she specializes, an additional 1 to 3. As a result, physicians will start work considerably later in life than nurses. Thus, when all of these factors are taken into account, the pay of many physicians is, in reality, less than that of nurses.

In emphasizing the United States' particular brand of “conspicuous consumption,” we risk losing sight of the real issue: universal access. Frankly, the question as it is usually asked ought to be reversed: Instead of “Why should we have a universal healthcare system?”, we should ask, “Why, of all industrialized countries, do we not?” There have been a number of answers, none of them satisfactory by themselves. As humans we are very much attracted to Ockham's razor, also called the rule of parsimony; in answer to a question, the simplest solution is apt to be correct ("Entities are not to be multiplied beyond necessity"). Unfortunately, Ockham's razor is sometimes defective and dangerous – causes are rarely that simple and complex questions rarely have simple answers. There are, I am sure, many reasons why the United States does not have such a system.

In 2 excellent papers written some years ago, Navarro claims that much of the answer lies in the structure of our labor movement.[14,15] There is, I believe, a considerable amount of truth in this even if other factors play a decided role. In Europe, at least before World War I, the labor movement was seen as transcending borders, including persons who work manually as well as intellectually. If the great labor leader Jauré had not been assassinated outside a Paris café, it is very well possible that the first World War would have been averted because the international labor movement on both sides would, in all likelihood, have refused to fight.[16]

Unions there were not divided into various craft unions (as the Gompers Cigar Makers were here) but felt that the interest of one was the interest of all. There was, in other words, a great deal of solidarity. In the United States, a union of all workers (be it manual or intellectual) was likewise developing the Industrial Workers of the World (IWW or “wobblies”) but posed a severe threat to capitalism. The union at the time of the Haymarket Riot and Pullman Strike was brutally smashed by private military as well as the US government.[17,18] The class gap and consequently the Marxian view of history as an evolving class struggle was not only economic but also educational. Socialists were interested not only in the material welfare of the worker but likewise in narrowing the educational gap between rich and poor.[19] In Europe, the so-called “Reclam books” were inexpensive paperbacks that published all sorts of things: from Shakespeare and Sophocles to Hemingway and Mann. It was not unusual to see construction workers having their beer with lunch while reading Goethe or Dickens. The Social Democrats sponsored lectures ranging from science to literature, and the “common man” was as likely as the university graduate to be well read; there was no reason for different “classes” to look down on one another. The Social Democrats were pushing for “universal healthcare,” which is the reason why the arch-Conservative Bismarck introduced universal access: He was far more interested in “pulling the teeth of the Socialists” than in providing for the people.[20]

The Communist scare after World War I – exemplified by the Sacco-Vanzetti case and by “Wilson's Secret War,” in which American and British troops tried to help the White Russians destroy the Communists – was in many respects a struggle of language. Capitalists as well as Bolsheviks (even if for different reasons) wanted to see Socialism equated with Communism. In the process they came close to giving Socialism a very bad name in capitalist countries, making people believe that the “Bolshevik” revolution was Communist and ergo Socialist. It was muddled thinking on both sides. Capitalist countries waved the flag of Bolshevism whenever Socialists tried to rally voters, and Bolsheviks attracted people to their side by claiming to be “Socialist.” That this latter claim was not true (Kautsky had left the Communists in order to form a more democratic party with Socialist principles) did not disturb Lenin, Stalin, or their capitalist opponents in the least as long as they could use that lie for their often diametrically opposed points of view. When Navarro claimed that the absence of a “universal healthcare system” was at least in part due to these different visions of what the class struggle entailed, he was, I think, in good part right.

Nevertheless, it is peculiar that Canada, with a workers' movement very similar to the United States', has a functioning, single-tiered healthcare system, as is the case in all EU countries. Canada in many respects has a social structure quite different from the United States'; it is a far less individualistic nation and has a very firm concept of the public good.

The Wilson and post-Wilson eras rather successfully wiped out those who tried to see in the promise of the Declaration of Independence[21] and Thomas Payne's The Rights of Man[22] a narrowing instead of a widening of the income gap. They lived in fear that the masses would not be held down by poor education. In fact, a memo accidentally released by the Trilateral Commission (a powerful assemblage of capitalist leaders) quite bluntly stated that “the worst we have to fear is the democratization of the masses.”[23,24] When Eugene Debs was jailed on a trumped-up charge (he was nowhere in the vicinity when the Pullman Strike or the Haymarket Riots occurred) he was released by no less than Warren G. Harding (a highly decent man even though unquestionably a Conservative) but was too ill to carry on the struggle. President Harding ordered his release to allow him to spend Christmas with his family. By then, Debs was a very sick man.[25]

The new leader of the Socialist party was Norman Thomas. Under his direction, which took place during the disastrous depression after World War I, the Socialist Party became a force to be reckoned with, especially after the 1932 presidential election, when it received a formidable number of votes and President Roosevelt derived much of the New Deal directly from the Socialist platform.[26]

Norman Thomas was equally interested in the education of the masses but failed to push it as had been done in Europe. Consequently, American workers frequently had no interest in further education and in fact often looked down upon those who had. It is difficult in an anti-intellectual society to convince laborers that education is in their best interests or that it could be interesting in itself. Thomas was surely devoted to the cause, but after the New Deal Roosevelt had effectively “pulled the teeth” of the Socialist tiger, similar to what Bismarck did when he introduced mandatory and universal health insurance in Germany. The difference, I believe, was that Bismarck's heart was really not in it, whereas Roosevelt's was.

In the United States during World War II, Henry J. Kaiser (a prominent shipbuilder on the West Coast who happened to have a social conscience) introduced his health plan for his workers. Kaiser represented the hospitals and Permanente (the metals company that managed Kaiser's shipyards) the group of physicians with whom they contracted. The resulting Kaiser Permanente healthcare system has since spread throughout the United States and for a long time has taken care of patients from all strata – not merely those who worked in the shipyard. It is a “not for profit” organization and could conceivably be used as a model for a national health plan.

Currently, larger employers offer a palette of insurance plans from which the worker chooses. The employer pays for part of the coverage and so does the employee. This is another reason why the market model cannot be used for healthcare. I, as patient, have nothing to say about the palette of plans offered, and if my physician does not happen to work for any of the plans my employer offers, then I have to change from a physician I was well acquainted with and liked to a complete stranger.

In many respects it is a vicious circle. We are a viciously individualistic nation in which individuals are seen as of primary importance and the community is important only to assure internal peace, protect us from outside interference, and make sure that freely made contracts are kept. But that is a purely “libertarian” vision and I seriously doubt that a nation committed only to these values could survive. Our “social safety net” may be extremely leaky and the holes may be large – but obviously we do recognize some public services (clean water, fire stations, police, roads, etc.) and do have, however deficient, a social network.

All of this boils down to the increasing control wielded by private insurance companies in the United States. In the EU many countries also work with private insurance carriers, but these are so tightly controlled that there really is no substantial difference between them. There are unions of teachers, railway employees, etc., but they all are tightly controlled by the government and there is little or no competition among them – ironically, one of the major reasons why the EU spends far less of their GDP! The United States spends close to 15% of its GDP on healthcare. The EU, in all countries except Germany – which has “basic care” but a thriving market above what they consider “basic” – spends considerably less on healthcare. If one wishes to look at outcome as one measure, longevity in the United States is lower (and continues to decline) than in the EU and infant mortality is a bit behind that of Albania.

Great Britain established a socialist, multi-tiered system in which those so inclined can buy supplemental insurance which will allow them to have a much shorter waiting time, their own pick of physicians, and many amenities lacking in the National Health Insurance plan. This has not turned out well. In a study done over a span of 10 years, the waiting time from suspected diagnosis to catheterization to (if need be) operation in the private sector remained at about 1 or 2 weeks for each. In the public sector, waiting time (which at the start of the study was close to that of the private sector) had gone to 365 days between each step – ie, 2 years from diagnosis to intervention!

This should not surprise anyone. Virtually all people who make these laws (ie, members of Parliament) are well-to-do and are the ones paying the taxes. It is in their interest to keep the basic health plan as inexpensive as it decently can be. Amazingly, repeated polls have shown that the British people are quite satisfied with their national health insurance.

It is no wonder that the United States has not had a “universal healthcare system” but that only for the last 10 or 15 years has this been seen as a primary problem. As the cost of healthcare goes up, industry has been greatly concerned about having to pay for part of their employees' health insurance and has, in part, joined the clamor for universal healthcare.

While there is no question that financial self-interest would be a factor in having physicians support universal healthcare, I do believe that physicians are much more motivated by curiosity, an ability to meld science with more humanistic concerns, and the thrill that comes with a proper diagnosis made or a patient who after a prolonged illness is cured. It is this – more than the desire to be able to be financially secure and enjoy those luxuries which time rarely permits – that motivates physicians Their complaints usually have little to do with personal salaries and mostly concern a constant feeling of frustration with the current “system” that strips them of their professional autonomy. They know that they are limited in the amount of time that they can spend with each patient because of the patient load that they are expected to care for, and that a new patient who hopefully will be a long-term patient should have an in-depth history, a thorough physical, and certain baseline studies performed. Their incapacity to do this for each of their patients takes most of the joy out of being a primary care physician. Moreover, because all of what little time they do have with patients is taken up with their medical issues or complaints, they cannot discuss the egregious errors of the current “system.” So, short of “paper strikes” – ie, continuing to treat patients but refusing to do any paperwork (a response I have long expressed as an ethically viable option and would have no problem endorsing) – what else would one have us do?