In her beautifully crafted essay [1], Dr. McMurray states that managed care threatens her dream to practice the admirable kind of medicine her father epitomized.

How is it that physicians, representatives of an old, honorable, independent profession, are threatened by managed care? Managed care companies offer a product: a physician chooses whether to be their agent. Why do physicians elect to be the agents, then bewail the results? Just how far down the road to serfdom have physicians traveled?

The answer for Dr. McMurray and other primary care physicians who decry the result of their adoption of managed care policies is to quit signing those contracts: That would illustrate the "guts" of which she speaks. Greater honor falls to those who take responsibility for their own actions. Either cheerfully accept the terms or decline to sign.

Can a practice continue that does not accept the dictates of managed care? I can only speak of my own experience. After residency in 1994, I joined a group that was heavily committed to managed care. I found this unsatisfactory, so I started my own internal medicine practice. In a region alleged to have one of the highest rates of managed care dominance in the United States, I take no capitation but participate in a few preferred provider organizations. My shortest standard appointment is 30 minutes, and I see 10 to 14 patients per day, do occasional house calls, and am sufficiently busy that I generally do not accept new patients. I do about as well financially as with the large group, and my level of satisfaction is higher. If I fail the Miz Lucys and Arthurs and Margarets in my practice, it is a result of my own inadequacies, not something I can blame on an administrator.

Dr. McMurray, you wish to "sound an alarm and rouse [your] colleagues to action." Don't bother. Take the high road! Show them leadership, courage! Don't participate in plans whose rules lead you to practice a type of medicine that appalls you. The financial rewards may not be as great, but we will be able to say we didn't abandon our posts in the fight to preserve the physician-patient relationship. And I'll wager your father would be proud.