Although I share Dr. Duffy's passion for physician-patient communication, I found preposterous his suggestion that "managed care organizations that view patient satisfaction and physician satisfaction as good business" might somehow be involved in a "real push to improve physician communication" [1]. I have never worked for any such managed care organization; the organizations I have worked for care little about what is best for their patients and care not a whit about physician satisfaction.

In my world, the absurdly low fees paid by managed care organizations have forced physicians to spend less and less time talking to patients. In fact, I have quit all but one of the eight health maintenance organizations I once belonged to because they paid me so poorly that I could not afford to spend sufficient time with my patients. In the few plans that did in some way tie payment to patient satisfaction, the incentives were minuscule.

I take pride in my communication skills, and I know that the extra time and effort I devote to communicating with my patients keeps them healthy and happy and keeps my hospitalization rate low and patient satisfaction rate high. Although both rates were the 10th best among 373 internists in one plan, was I rewarded in any way? On the contrary, I was penalized because, with longer and more thorough office visits, my utilization of evaluation and management services was above the plan's norm.

Although managed care organizations may give lip service to better physician-patient communication, until they put their money where their mouths are, they will remain a major part of the problem, not a solution. If, as Dr. Duffy suggests, we internists are to embrace the "skill of dialogue," it will be because we have the best interests of our patients at heart; the managed care organizations that I have participated in certainly do not.