During my psychiatric training, I occasionally came across clinicians who seemed to believe that all individuals are profoundly influenced by unconscious forces--all individuals except the psychotherapist, that is. I was reminded of this odd notion when I read Dr. Harold Eist's president's column in the November 1 issue titled "It's Time to Speak Out Against Economists' Balderdash."

Does Dr. Eist not believe that a psychiatrist who may be struggling to pay a child's college tuition bills or finance care for an elderly parent (as many are) isn't unconsciously influenced by his or her own financial concerns when he or she makes health care decisions or recommendations? While we may have chosen and worked hard to participate in a most noble profession, we remain human beings, just like our patients, and subject to the same psychological influences. To acknowledge this isn't shameful any more than is acknowledging a countertransference reaction in therapy. We simply must be vigilant so we don't act out these influences to the detriment of our patients. Denying their existence is naive at best and only increases the risk of acting them out. The notion that we as physicians are "above" this type of influence, driven only by "the altruistic need to serve" and are thus somewhat closer to God, is an insult to all others, including economists, who also strive to enrich the lives of others, limited by the same frailties as we.

Any health care financing system encourages financial abuses when a third party instead of the patient is responsible for paying the physician and where the patient is insulated from the financial burden of the care he or she is receiving. This is regardless of whether this third party is "silent" as it was for 50 years before managed care entered the scene in the early 1980's, or the more controlling third parties of today known as "managed care." The issue isn't whether it's "fee for service" or not; it's who is assuming economic risk.

The undiluted ecomomic "tension" between the patient and his or her physician is the most efficient method of limiting the impact of unconscious, self-serving influences on health care decision making by all clinicians.

Steven D. Field, M.D.

Northbrook, Ill.

(Psychiatric News, January 17, 1997)