Dr. Reich is right: Quality, not time, is the ultimate issue in medical care. As I tried to make clear in my editorial, however, while adequate encounter time is a necessary condition for high-quality practice, it isn't sufficient. Many other things are needed, including adequate funding for the preventive services identified by Dr. Reich. In that connection, the recent passage of the Balanced Budget Act of 1997 for the first time provides Medicare funding for many preventive tests and procedures, perhaps a sign of better things to come.

Limiting reimbursement for a unit of clinical care is clearly attractive to health system managers. First, it has the potential to reduce costs. But it also increases productivity by putting pressure on clinicians to see more patients per unit time, because that is the only way they can preserve total income. Thus, as Dr. Volpintesta suggests, the marketplace has many subtle ways of intruding into the examining room. The intrusion is not always to the benefit of patients, which is exactly why physicians, patients, and the public need to call a halt to the erosion of encounter time.

Dr. Volpintesta also makes the point that ordering tests may be a "time saver." I certainly agree that ordering the right test at the right time is important. But virtually every study on the subject has shown that skillful, informative, empathic discussions with patients and families are far more influential in reducing the risk for malpractice action than the ordering of additional tests. And good discussions take time-QED.