I've read that diet counselors are receiving $250 to $700 per hour to coach people through their eating crises. It is pathetic that a pediatrician cannot get $200 for an hour consult. And when PAs and NPs have the same practice rights and authority as physicians, it seems futile for us to fulfill CME requirements. As we raise our standards of practice it is being lowered at the other end.

There is no good advice you can really offer us on the future. But if I go back to school to become a nurse practitioner, I can open my own office and perhaps practice cosmetic dermatology, perform procedures and sell skin products, and reap my just rewards at last.

Jonathan Pasternack, MD
Delmar, NY

Family practitioner Paula J. Hartzell's "Medicine is a blame game" ["The Way I See It," Apr. 20] is sobering. I agree with her commentary entirely.

After 32 years, I am totally disillusioned with medical practice and all the hassles associated with trying to care for patients. Let's go down the list:

• The government and health insurers blame doctors for overcharging patients.
• The legal profession blames doctors for practicing poor-quality medicine—while these same lawyers are getting rich off the system.
• Regulatory agencies blame us for not doing enough or spending more time in the office.
• Liability insurers blame us for the ever-increasing number of lawsuits.

Meanwhile, organized medicine appears powerless, sitting on the sidelines. If the current trend persists, I am afraid we are heading for a medical meltdown. Perhaps future topics in Medical Economics will be: Where are all the doctors?

Richard H. Rowe, MD
Mesa, AZ

I agree totally with FP Paula Hartzell's sad commentary on the current state of our malpractice system. The overwhelming majority of doctors are caring, compassionate, and dedicated. Even minor errors drive us crazy, and the thought of doing something that may possibly have harmed a patient is devastating. Destroying these doctors in a malpractice suit is despicable.

Our current system puts doctors in the impossible situation of over-investigation and documentation ad infinitum, vs the need to control costs for insurance companies while seeing enough patients to earn a living.

I have had the chance to observe a different system. As a locum tenens, I spent a year in New Zealand. Malpractice, called "Medical Misadventure" there, was covered by ACC—a sort of workers' compensation fund paid for by individual taxes and accessible by filling out a simple government form. It ensured all medical costs were covered, and some income went to the individual affected. No lawyers, no court fights. Meanwhile, the Medical Council of New Zealand—staffed by doctors and nurses—investigated the allegations to see if there was a breach of duty to the patient. It allowed for injured patients to be compensated in an expeditious manner, and made sure that review occurred at the hands of disinterested peers. And just maybe, it could have saved Dr. Hartzell an ordeal none of us should ever have to face.

Wayne S. Strouse, MD
Penn Yan, NY

"Good" tobacco?

I read with interest Dr. Daniel Katz's letter ["Readers React," Apr. 20] advising his tobacco-addicted patients to quit smoking by buying a pipe and good tobacco. Just where does anyone purchase "good" tobacco? Perhaps our dental and oral surgeon colleagues would disagree with his implication that smokeless tobacco is less harmful than cigarettes.

Rebecca P. Conway, MD
Huntsville, AL

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