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LETTERS TO THE EDITOR Dear Sir: I have read Dr. Orient's essay inPerspectives [1] and would like to clarify one of the segments relating to the doctor-patient relationship. Dr. Orient makes two points: First, diat in die fee-for-service system the patient is in control as "employer" while the physician is "servant," and in this context where die customer decides, noncompliance is "meaningless." I do not believe diat fee-for-service practitioners see this as their real world, and a search ofthe literature does reveal that they encounter a serious problem of patient noncompliance [2]. Second, Orient asserts (like the Marxists she abhors who proclaimed die inevitability of revolution and predicted incorrecdy bodi the conditions and the country in which it would first erupt) that "conflicts are inevitable" in prepaid practice because provider and consumer do not have common interests. But die September 1981 issue of theJournal ofHealth and Social Behavior has an article, "Client Satisfaction and the Organization of Medical Practice," in which die authors compared fee-for-service solo practitioners and prepaid multispecialty groups [3]. Initially finding no differences in client satisfaction widi diese very different types of practice, they tried to account for this apparent anomaly. Their findings: Clients enter HMOs and other prepaid groups widi negative expectations, but enter solo practice relationships with positive expectations. However, their experiences with solo tend to be negative compared with the experience of clients of the odier type of groups. Experiences accumulate and, over time, they offset expectations. REFERENCES 1.Orient, J. M. The grand inquisitor and the role of the state in medical economics. Perspect. Biol. Med. 25:20-38, 1981. 2.Practitioner or patient—who is in charge?/. Health Soc. Behav., pp. 227-228, September 1981. 3.Ross, C; Wheaton, B.; and Duff, R. S. Client satisfaction and the organization of medical practice./. Health Soc. Behav., September 1981. Jacqueline Westerman 201 East 69th Street New York, New York 10021 Permission to reprintaletterprintedinthis section maybeobtainedonlyfrom the author. 338 I Letters to theEditor Dear Sir: The fashionable term "compliance" is used in several contexts, all implying the presence ofsome kind of force or authority: a change in volume per unit change in pressure, adherence to a bureaucratic regulation, and taking medicine as prescribed. Without a hterature search, I know that many of my private patients disregard my advice, just as many of my veterans and county patients did. I do not therefore stamp them "noncompliant." I may try to explain the instructions better, or I may modify the advice—remembering that the customer may be right. George Washington would have lived longer had he been noncompliant, however prestigious the physician who ordered him to be bled. Though Ms. Westerman makes an issue of prepaid practice, I mentioned it only once, to point out that die providers profit from minimizing services, and the consumers "get their money's worth" by maximizing demands. The paper by Ross, Wheaton, and Blair is an interesting exercise in multiple regressions, but the conclusions stated are hypotheses, not findings. Expectations were not measured but inferred from the intercept of a regression Une. Patients were not followed over time; rather, the length oftime a patient had been associated with a practice was entered as a variable in a regression equation. Patients who stay in a group for a long time (especiaUy if they must make regular payments) would appear to be self-selected for satisfaction. Not surprisingly, patients have different preferences and in a free society are generaUy satisfied widi the style of practice they have chosen. I am not opposed to prepaid practice, so long as I am not required to participate . Though patients may receive excellent care in such settings, the stimulus of competition from the fee-for-service sector may be crucial. As long as we have alternatives, our inevitable conflicts can be resolved peacefully, if necessary by taking our business elsewhere. Jane M. Orient 3615 E. Fifth Street Tucson, Arizona 85716 Dear Sir: Professor Mittwoch's delightful essay on biological and historical aspects of abnormalities of sex determination and sex differentiation [1] will surely provoke much thought, if not outright rejoinders, especially on the hermaphroditic nature of Adam. Yet it...


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