I got this posting from an Emergency Medicine Listserv that I subscribe to, and I just had to respond... I'll probably get flamed to death for it, but I just felt like I had to ramble a bit... (I've covered the name of the original posting for anonymity, but the response is what I posted to the list)
I was listening to the local NPR station this AM. They were doing a feature about the public defender system. The concept that indigent criminal defendants are entitled to a court appointed attorney has been operative for ~40 years. Up until recently, in most jurisdictions, the attorney was appointed at no charge to the defendant. However, the attorney still gets paid, by the state or local government. The point of the piece was a discussion of the recent trend toward charging the defendant a nominal amount for the attorney's services. The state being profiled was, I believe, Wisconsin, which recently passed legislation requiring a $50 (total, not per
day) payment by the defendant. The payment is due within 30 days of the attorney being assigned. Of course, the attorney is paid regardless of whether the defendant pays or not. None the less, some of the attorney's were quoted were aghast at the idea that their clients might have to cough up $50 in return for thousands of dollars of legal fees. I guess the high ground is easier for them to achieve than it is for me.
Interesting. Politicians decide that criminal defendants have a right to an attorney even if they cannot afford one, and set up a system to provide it.
Sounds a bit like EMTALA, doesn't it. The politicians decided that people have a right to access the ED 24h/day without regard to ability to pay. So they set up a "system" to provide the care. One difference though. The attorneys get paid for representing their criminal defendants. But the system the politicians set up for "free" emergency care doesn't provide payment. WE (EP's) pay for with longer hours, smaller paychecks, etc. Gee, I wonder if that has anything to do with the power of the legal lobby and that many politicians are lawyers?
We are sheep. Why did we ever agree to work for free? Do our colleagues do it? Only on true "emergencies" once we've separated the wheat from the chaff. Do lawyers do it? Sometimes they do, it's called "pro bono". But it is done at their convenience and pleasure, and they think it makes them morally superior creatures to be providing that occasional free service. For many of us EP's, if consider both no pay and Medicaid (which is the next thing to "no pay", at least here in the People's Republic of New York), 50% or more of what we do is "pro bono".
Think how much nicer your career would be if your work was almost always paid for. You could work 1/2 as many hours or make 2x as much money. For indigent patients, in a real emergency, the government would pick up the tab. Otherwise, no pay, no service. Except when you were feeling generous, just like the lawyers. Then you could go home self satisfied, with a puffed chest, and boast to your family how you took a couple of "pro bono" patients today.
R** *. K***, MD
******* Dept. of Emergency Medicine
PS: before the bleeding hearts jump on me, the above was mostly tongue in cheek.
RK
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and the response:
Some interesting points to consider:
1) Pro-bono work, which is not the same as the public defender system, averages about 40-42 hours/year for the roughly 45% of attorneys that participate, for example, in the State of New York (1997 statistic).
a) this is time/work product (counted only in "billable hours") donated to a person/client/cause that the attorney knows up front has no possibility of payment; at least philosophically, if not practically, somewhat different that the EP's situation, where we are supposed to be (at least theoretically) blinded to the capabilities of our patients to pay. It is only in the statistical post-treatment analysis that we consider how much we have "donated."
b) there is also somewhat of a skewing of the perspective in that deliberately inadequate or incomplete or reimbursement by HMO's and insurance companies are counted as "payment" for service rendered.
c) lawyers still do put up with all the other problems of running a business, with clients that refuse to pay, or are slow to pay, just like physicians and hospitals.
d) I think you would be hard pressed to find an attorney that would seriously say that because he does pro-bono work, that he is morally superior in any way, shape or form. For anyone of us, physician, attorney, or janitor to claim such a position over our fellow man would be, in my humble opinion, truly arrogant and clear evidence of the exactly the opposite.
2) As for the payment of public defenders by various jurisdictions, this is to compensate them for work contracted by various attorneys and firms in lieu of running a full time public defenders office, rather than time "donated" or "volunteered" by firms. It should not be equated with pro bono work in any form. It merely provides a way for jurisdictions to conveniently provide the Constitutionally guaranteed right (6th Amendment) of representation without having the administer an full-blown (and often, more expensive) office of the public defender.
My small perspective is that pro bono work is volunteerism, pure and simple.
It is no different than physicians donating time in a homeless clinic or for a missionary clinic. It makes neither lawyers nor physicians any more entitled to claim the moral high ground for themselves, no matter how much or how little good you may think you are doing.
As to the question of whether or not EP's are sheep, that I cannot answer; having recently hung up my spurs after just short of 13 years of full time and 5 years of part time practice, and traded them in for a place as a full time law student, I have always felt that what I did as an EP was honorable and reasonable. However, it has always been my contention that we as physicians (and perhaps more so among EP's) have been bred to be loners, the captain of the ship, the Lone Ranger, as it were. We are deeply and intensely mistrustful of the decisions of other and have never learned to work for the collective, and therefore have been easy to divide and conquer, by legislature, by insurance companies, by attorneys. Crying over the perceived inequities of reimbursement and payment between physicians and attorneys or whomever we wish to compare ourselves to (insurance CEO's and Bill Gates top my list...) only to serve undermine any possibility of unity in the battle for fairness.
That being said, however, I should point out that we should not let our rhetoric and quest for what we perceive to be fair pay rise to such a level that we risk sounding like a bunch of whining spoiled brats, as many attorneys have, as evidenced by such web sites as www.greedyassociates.com .
We make more than the vast majority of the American working class, with much less discomfort and risk than many of our fellow workers. I, for one, would not wish to trade my position for that of an infantryman, or an inner city schoolteacher, or a city police officer, or an iron worker, or any number of very necessary and very honorable professions. One of the risks that anyone who works in a difficult and harsh environment runs is the development of a pervasive cynicism and loss of humanity that blunts our perspective to the needs of those around us. Yes, fight for what is fair, fight for what is right, but keep in mind that the final winners should not necessarily be the physician and his paycheck, or the profession and its status and power, but the patient and the public at large.
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