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Private practice is unethical—and doctors should give it up

BMJ 2015; 350 doi: (Published 05 May 2015) Cite this as: BMJ 2015;350:h2299

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Is private practice of medicine unethical?

John Dean wrote in a Personal view in BMJ (1) that the private practice of medicine is unethical and that doctors should leave. I have worked in public national medicine for 39 years and 31 years in public and private medicine, and I disagree with many of the claims made by John Dean.

Although I do not know exactly the functioning of the National Health Service (NHS) in the UK, I imagine it will be similar to the Spanish NHS, and, if so, I would state my disagreement with these views.

In Spain, in the 1980s exclusive dedication to public hospitals was introduced. Doctors who welcomed it, with the same working hours, had better pay. The fundamental reason that was exposed by the then health minister was that the doctors under exclusive contracts consecrate their free time in the afternoon to study the problems of their patients, however, those working in private medicine in the afternoons could not. This never happened. Most doctors who were exclusively dedicated, then and now, for the evenings were dedicated to their hobbies and favourite sports, to be with their family or out walking. The other, without exclusive dedication, devoted the evening to work and study to compete with other doctors to have more patients (clients).

In Spain, the best doctors in the hospitals, in general, are those that also have private consultation. Previously, these doctors used to be department heads. Lately, because to be head of a medical or surgical hospital service is almost a sine qua non to have exclusive dedication, these charges are granted to mediocre doctors. Public hospitals in Spain are governed by politicians and are these who appoint managers of hospitals, which are usually chosen to be of the same political color or between relatives or friends.

Also John Dean said that the public medicine fellow may be asked aid for diagnostic problems you have and this can´t be done in private because they are competitors. Precisely what does not exist in public hospitals in Spain is competition between doctors and that's not good for patients. Best and the worst doctors have the same salary in the hospitals and this ends up discouraging to the most competent doctors.

John Dean also refers to the lack of honesty of private medicine. I do not agree. The four Hs a doctor must have as William Osler said are honesty, humanity, humility and humor, and all doctors need them either practising in public or private healthcare. Another thing is that doctors working for private insurers might become dishonest and do more testing and make more revisions to a patient without needing them. I do not work for private insurance companies, but if I did I am convinced that it would be equally honest.

John Dean, after practising private and public medicine for some time, has come to the conclusion that it is unethical. It happened to him like St. Paul, when he fell from his horse. If it is unethical, why did he practise it? Is private medical practice unethical or are some doctors unethical who practise it, like other doctors in national medical practice?

I conclude with this quote from Ayn Rand, who said that "Doctors are not the servants of their patients. They are traders like everyone in a free society, and should be proud of the title because the services they offer are of crucial importance".

1. BMJ 2015; 350:h2299

Competing interests: No competing interests

23 June 2015
Joaquín Lamela López
Pulmonary Medicine M. D.
Complejo Hospitalario de Orense (Spain)