I wholeheartedly agree with my colleague Mary Ann Bauman that there are many positives to being a doctor (see "Last Word: We don't have it so bad," June 17, 2005). We know our patients as friends and acquaintances in the community, as the parents of children in school with ours. We're privy to their secrets and personal problems. Our profession enables us to aid the sick and preserve the well. Yet despite all the nobility, honor, and privilege of our profession, we're under siege from every side.

Our profession is highly regulated by law and supervised by federal and state agencies. Physicians waste an inordinate amount of time on paperwork. We must be knowledgeable about and compliant with every health law, not to mention billing codes and Medicare rules. In addition, as independent physicians—those who don't choose to clinically and financially integrate—we're prohibited by federal law from banding together to negotiate with payers.

We're among the few professions that perform vital services for patients, yet we must look to third-party payers most of the time for reimbursement for those services. Managed care plans require that a physician accept all patients who choose him, dictate how often he may see the patient, the amount he'll be paid and when, and, in many instances, what he can prescribe. They can rescind previously paid compensation at will, and do. In reality, HMOs are practicing medicine since they must approve every test, course of treatment, and referral to a specialist, yet they are rarely, if ever, legally responsible. Meanwhile, the physician is left to suffer the consequences of any malpractice suit.

Patients' deductibles, copays, and premiums go up every year. The health insurers and HMOs are profiting ruthlessly and arrogantly from patients and physicians. We get to read published reports of HMO senior management reaping millions of dollars in salary and bonuses, and they're laughing all the way to the bank.

We spend valuable staff time on insurance referrals and precertifications, and have to hire additional staff to complete requirements that are barriers to care. This raises the cost of care and decreases patient satisfaction and medical safety.

The personal injury area of the legal profession encourages patients to become our enemies and seek compensation for any maloccurrence. Physicians are often pressured or forced to settle otherwise defensible cases. I believe that this plays a role in increasing our professional liability rates.

Many states are experiencing a malpractice insurance crisis. In some areas, physicians find it hard to obtain coverage at all, let alone at affordable rates. The liability insurance companies settle nonmeritorious claims routinely, with or without our consent, depending on the policy. While the patient gets his day in court, the physician may not, and we cannot protect our reputations.

Our overhead continues to grow and our reimbursements do not increase yearly. We're constrained to make more from less. The crisis isn't looming; in most states it's here.