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	Since this article does not have an abstract, we have provided the first 150 words of the full text and any section headings.

I concur with the interesting article by Sulmasy et al¹ regarding cost-control arrangements that are perceived as ethically objectionable by physicians. Having practiced primary care medicine for 20 years, I have witnessed the change in medicine as loyalty to managed care companies for cost containment has taken precedence over loyalty to patients. But there is more.

Many physicians have sold their practices to hospitals. Those physicians have to manage the bottom line, not only for managed care companies, but also for their employers. Many of these relationships have financial and bonus incentives. Some systems are riddled with corruption.² There is a real fear of a cut in income or, worse, the loss of a job if productivity and cost containment are not adequate.

The new system has bred 3 groups of physicians. There are those who have recently completed training and are relatively new to the system. These physicians have . . . [Full Text of this Article]